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MDEQ USE ONLY

RENEWAL APPLICATION

POLLUTION CONTROL OPERATOR CERTIFICATION
Mississippi Department of Environmental Quality

Place Pre-Printed Label Here

Expiration Date:

I hereby certify that the information contained within this application is true and accurate. I further understand that providing false information on this application is grounds for revocation of certification.

DATE:

Date:

By:

Type Trmt:

First

Middle

Street, Rural Route or P.O .Box

City

State

Zip

Work

FOR MDEQ USE ONLY

Approved Hours

Other MDEQ

Class Certificate:

I  II  III  IV  I-C  II-C

 (Circle One)

IV. RENEWAL FEE: $45.00 (PAYABLE TO:  STATE OF MISSISSIPPI)

III. CONTINUING EDUCATION CREDIT (ATTACH COPIES OF ALL CEC CERTIFICATES)

*Employer: 						

Address:

Name:

*Email: 						

Date Employed (mm/dd/yy) 			

 (COMPLETE SECTIONS  I AND  II  FOR ALL INFORMATION  INCORRECT OR NOT INCLUDED* ON LABEL)

*Phone:

*Phone:

*Address:

Certificate Number:

Explanation:

Certificate #:

Certificate Class:

Exp: Date:

Approved:  Y  N

Fee Paid:  Y  N

V. SIGNATURE:

Check Attached:

Money Order:

Other (Specify)

Total Approved Continuing Education Credits:

Cell

II. CERTIFICATION

Social Security No. (Last 4)

I. APPLICANT

Date(s) of  Training

MDEQ Sponsored

Hours

Training Activity / Sponsor

Please list below all of the facilities for which you currently are listed as the certified operator.
(Make copies of this page and attach if needed)

Instructions

Type or Print all information

Section I

Section II

Indicate which Class of Certification you are applying for and include your Current Certificate Number and the Expiration Date of the Certificate.

Section III

Section IV

Be sure to include a check or money order payable to the STATE OF MISSISSIPPI for the $45.00 application fee. The application cannot be processed if the fee is not paid. Check or money order should be Stapled or Clipped to the application. 
We are not responsible for lost checks if not attached.

Section V

Be sure the application is signed and dated in blue ink by the applicant to Identify it as an Original. The application cannot be processed if not signed.

Name of Facility	County	NPDES Permit No.	

			

			

Must use an Original Application. Copies Will Not Be Accepted.

Be sure to keep a copy of the completed application for your records 

Allow 6 to 8 weeks for issuance of certificate

If, for any reason, certification renewal is denied, the application and fee will be returned.

Attn: Accounts Receivable
Department of Environmental Quality Office of Pollution Control
P. O. Box 2339 
Jackson, MS 39225-2339

Mail Application to:

List all training you participated in over the past three years for Continuing Education Credit (CEC). All Training must be approved by MDEQ to be eligible for credit.   Exceptions will be made for operators living and working outside the State of Mississippi.  You must attach Copies of all attendance certificates.  Do Not Send Original Certificates. CECs required for certificate renewal may differ depending on type of certification and how long the applicant has been certified. Refer to the Regulations for the Certification of Municipal and Domestic Wastewater Operators for specific requirements.

Check the information on the pre-printed label. If this information is Incorrect or Incomplete, Make Corrections in the space provided. Provide Last Four Digits of your Social Security Number, Phone Numbers and Current Employer Information.

Application must be Fully Completed, Signed and Dated