Get Wv Dhhr Form Ew 212

Form EW-212 May 2012 Fax to 304 558-4322 or mail to C T Program 350 Capitol Street Room 313 Charleston WV 25301 www. wvdhhr. org/oehs/eed/swap/training certification C T Use Only Date Received // Staff Lead Not a complete submission returned Request for Water or Wastewater Operator Certification Renewal Print legibly and fill out completely. Incomplete applications will not be processed* Use NA if not applicable. Submit 30 to 60 days before the expiration date. Application Date mm/dd/yy // Date of Birth mm/dd/yy // First Name Last Name Middle Initial Suffix Home Phone Home Address City State Zip County Is this a new address Yes No Note This is the address C T will use to mail your certification related information* If your home address changes you are responsible for notifying C T. Certification WVOP Email Please check which certification you need to renew Water Wastewater Class I Class I 125 fee WDS 1D OIT Class IV 200 fee 25 late fee Note Please include a check or money order payable to WVBPH where applicable. Please list course information below and attach copies of your completion certificates keep your original certificates for your records. If additional space is needed attach information to this form* Approved CEH Course Title Course Sponsor Length of Hours Date s attended Note Only Commissioner approved CEH courses apply. Please ask course providers for WV CEH approval information prior to registering or allow additional time for WV CEH consideration by submitting an EW-78. I certify to the best of my knowledge all information provided on this form is true and accurate. I certify I have read understood and complied with all the laws of WV under the provisions of 64CSR04 Public Water Systems Operators and/or 64CSR05 Wastewater Systems and Operators. wvdhhr. org/oehs/eed/swap/training certification C T Use Only Date Received // Staff Lead Not a complete submission returned Request for Water or Wastewater Operator Certification Renewal Print legibly and fill out completely. Incomplete applications will not be processed* Use NA if not applicable. Submit 30 to 60 days before the expiration date. Incomplete applications will not be processed* Use NA if not applicable. Submit 30 to 60 days before the expiration date. Application Date mm/dd/yy // Date of Birth mm/dd/yy // First Name Last Name Middle Initial Suffix Home Phone Home Address City State Zip County Is this a new address Yes No Note This is the address C T will use to mail your certification related information* If your home address changes you are responsible for notifying C T. Application Date mm/dd/yy // Date of Birth mm/dd/yy // First Name Last Name Middle Initial Suffix Home Phone Home Address City State Zip County Is this a new address Yes No Note This is the address C T will use to mail your certification related information* If your home address changes you are responsible for notifying C T. Certification WVOP Email Please check which certification you need to renew Water Wastewater Class I Class I 125 fee WDS 1D OIT Class IV 200 fee 25 late fee Note Please include a check or money order payable to WVBPH where applicable..