IOWA WATER ENVIRONMENT ASSOCIATION

VOLUNTARY COLLECTION SYSTEM OPERATOR CERTIFICATION

RENEWAL APPLICATION FOR 7/1/2013 THROUGH 6/30/2015

APPLICANT INFORMATION (PLEASE PRINT)

NAME: ______CURRENT COLLECTION SYSTEM CERTIFICATE

NUMBER (UPPER LEFT HAND CORNER) ______

MAILING ADDRESS DAY TIME PHONE: ______

STREET: ______EMAIL ADDRESS: ______

CITY: ______Are you also certified by IDNR as a Water

Or Wastewater Operator? _____Yes _____No

STATE: ______If so, what is your IDNR Operator ID No.?

IDNR Operator ID Number ______

ZIP CODE: ______

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LIST DIRECTLY RELATED CEUs EARNED 4/1/2011 THROUGH 3/31/2013

(SEE INSTRUCTIONS FOR SAFETY TRAINING LIMITATION)

COURSE TITLE AND LOCATION CEUs EARNED DATE TAKEN

______

______

______

______

______

______

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APPLICANT CERTIFICATION

I HEREBY CERTIFY that this application contains no willful misrepresentation or falsification and that the information given by me is true and complete to the best of my knowledge and belief. I am aware that should investigation at any time disclose any such misrepresentation or falsification, my application will be rejected, my certificate will be revoked, and I will be disqualified from applying in the future for any certification under the jurisdiction of the IOWA WATER ENVIRONMENT ASSOCIATION.

SIGNATURE OF APPLICANT: ______DATE: ______

INSTRUCTIONS

  1. Complete all sections fully and accurately.
  2. Renewal fee is $20.00 and is not refundable and is not transferable. The renewal certificate will be valid for the period 7/1/2013 through 6/30/2015.

3.  Make check payable to the Iowa Water Environment Association

  1. Renewal applications must be postmarked by June 30, 2013.
  2. Renewal applications postmarked after June 30, 2013 but prior to August 1, 2013 will be assessed a $10.00 late fee, which must be paid prior to issuing the renewal certificate.
  3. Renewal applications postmarked August 1, 2013 or later will be returned to the applicant and the applicant’s certificate will no longer be valid.
  4. Class I and Class II renewals require that the applicant earn a minimum of 1 CEU during the period April 1, 2011 through March 31, 2013 by attending training sessions or completing course work in a directly related area.
  5. Class III and Class IV renewals require that the applicant earn a minimum of 2 CEUs during the period April 1, 2011 through March 31, 2013 by attending training sessions or completing course work in a directly related area.

9.  For all Certification Classes, CEU credit for safety training is limited to 20% of the CEU requirement. Approved safety topics are: backhoe operator; blood-borne pathogens; chains, slings, wire rope; confined space awareness; excavations, competent person; excavations, trenching/shoring; haz. Com/right to know; Iowa One Call; ladder safety; lockout/tagout; personal protective equipment; respiratory protection; safe handling of materials; traffic control/work zone safety.

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Mail the completed renewal application form and fee to:

IAWEA, c/o Ames WPC Plant

56797 280th St.

Ames, IA 50010

If you have questions, contact Glen Petersen at:

712/332-5985 or

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ED. 08/12