Listed Consultant Program - Individual Form
(Environmental Scientist)
Article 2, Part 3
Attach
this individual application form
to the COMPANY application form |
|
Individual Listing #
(Leave blank. For OIS use only.) |
| Name |
Phone # ( ) |
Fax # ( ) |
Mailing address:
Company
Street or P.O. Box
City/State/ZIP
|
| Years of qualifying experience:
years. "Qualifying
experience" means experience pertinent or related to site assessments, remedial
investigations, and corrective actions necessary to remediate petroleum-contaminated water
or soil. If you do not have at least five (5 years) of qualifying experience, STOP HERE.
You do not meet the minimum requirements to be listed as an environmental scientist. |
| Check each box that applies. If
you cannot check at least one of the following boxes, STOP HERE. You do not meet the
minimum requirements to be listed as an environmental scientist. |
|
I am a registered
professional engineer. Reg. #
. Exp. date
.
Issuing state I am a registered professional geologist. Reg. #
. Exp. date
. Issuing state
Other professional certification. Attach separate page with name, issuing agency,
expiration date, criteria.
I am a graduate of an institution of higher education that is accredited by a regional
or national accrediting agency. Name, city, state of institution: . I have
successfully completed (grade of "C" or better) at least 30 semester (or 45
quarter) hours of undergraduate or graduate work in one of the following: engineering;
industrial hygiene; a biological, chemical, environmental, or physical science. |
|
|
|
| Have you ever been convicted of,
entered into a plea agreement, or entered a plea of nolo contendere to any crime involving
a violation of Colorado or federal environmental laws or regulations, including any
violation of laws or regulations governing Colorado’s Petroleum Storage Tank Fund? If
you checked "yes," STOP HERE. You do not meet the minimum requirements to be
listed as an environmental scientist. |
No
Yes
|
CERTIFICATION
I hereby certify that the information provided on this document is true and complete to
the best of my information, knowledge and belief. I will notify the Oil Inspection Section
within 30 days of any change in this information. I understand that providing false
information may cause my Listing status to be revoked and may subject me to criminal
proceedings and penalties. I authorize the State of Colorado and any agent acting on its
behalf to conduct an inquiry into any information provided in this document. I agree to
cooperate with such inquiry to the best of my ability, and to provide to the Oil
Inspection Section on its request documentation to support any information provided
herein, including official "sealed" college/university transcripts and
professional licenses.
Date Signed
Print/type name
| Subscribed and sworn to before me in the county of
, state of
on this day of ,
200 . My commission expires
.
Notary public signature:
|
|
