Application For Contractor Approval printable pdf download

Application For Contractor Approval

Application for Contractor Approval

I. Applicant Information:

Company Name: _______________________________________________________

Email Address: ________________________________________________________

Owner: ______________________________________________________________

Phone Number: _______________________________________________________

Fax Number: __________________________________________________________

Business Address: ______________________________________________________

City: ___________________________________ State: ______ Zip: ______________

Name of Qualifying Party: _______________________________________________

State ID for Qualifying Party: _____________________________________________

State of Issuance: ______________________________________________________

II. Certification of Compliance:

I, ____________________________________, do hereby certify that:

(Owner/Qualifying Party)

Each person who conducts activities for the company is annually accredited in

accordance with the provisions of the State; The company has access to at least one

disposal site permitted to receive contaminated waste that may be generated during

the term of the license; The company possesses worker protection and medical

surveillance programs that are consistent with the requirements of the Occupational

Safety and Health Administration; An accredited lead project supervisor shall be

present at all times during the project; The company shall maintain all records as

required by state law.

III. Statement of Compliance / Citation (Please check one): This disclosure shall include a

signed statement that all penalties and fees assessed to the applicant shall have

been paid in full.

[__] I have not been cited for violating the environment standards, regulations, or

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Application For Contractor Approval