Application For Contractor Approval (Page 2 of 3) in pdf

Application For Contractor Approval Page 2

laws of any state or federal regulatory agency.

[__] I have been cited for violating the environmental standards, regulation, or laws

of any state or federal regulatory agency. (Please include evidence that all

penalties and fees accessed have been paid in full).

Are you now performing, or in the past five years have you performed any services that

you are now applying for?

[__] Yes

[__] No

If yes, please specify the state and name of the company:

________________________________________________________________________

IV. Letter of Approval Fees for Contractors: $500 for Regular Processing and $750 for

Emergency Processing. Applications for regular processing are reviewed in order of

receipt and may take up to thirty days. Applications for emergency processing will

be reviewed and processed in five days or less after receipt of the required

documentation. Fees are paid the State Department of Environmental Quality.

Please submit all application materials and appropriate fees to the following

address:

Address: _____________________________________________________________

City: _______________________________ State: _______ Zip: _________________

V. Statements of Regulation Knowledge and Acknowledgement for Public Records:

I hereby certify that this application, all accompanying documents, and information

provided is true and accurate in accordance with state law, which states that any

person who willfully or knowingly makes any false statement, representation, or

certification in any form, application, record, label, report, plan or other document

filed or required to be maintained under this Subtitle are subject to penalties with

conviction of civil and criminal actions as outlined in this regulation.

I hereby acknowledge that the information I have provided on or with this form is to

be kept in the public records maintained by the State Agency. I also acknowledge

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Application For Contractor Approval Page 2