Get Operator Employment 2016-2024

DEP-065 01/2016 State of New Jersey Department of Environmental Protection Licensing and Pesticide Operations Mail Code 401-04E PO Box 420 Trenton New Jersey 08625-0420 www. nj. gov/dep/exams SECTION I LICENSED OPERATOR IN CHARGE EMPLOYMENT NOTIFICATION FORM-WASTEWATER Applicant Phone Numbers 1. Signature authorized representative of requesting facility Printed Name Title Any changes in this employment should be forwarded to this office at least two weeks prior to the job termination by completing another DEP-065 Licensed Operator In Charge Employment Notification Form. If you have any questions please contact the Licensing Unit 609 292-4911. DEP-065 01/2016 State of New Jersey Department of Environmental Protection Licensing and Pesticide Operations Mail Code 401-04E PO Box 420 Trenton New Jersey 08625-0420 www. nj. gov/dep/exams SECTION I LICENSED OPERATOR IN CHARGE EMPLOYMENT NOTIFICATION FORM-WASTEWATER Applicant Phone Numbers 1. Home 2. Business Facility Name 3. Emergency Applicant Signature Facility Classification Mailing Address City State Zip Applicant Name please print Home address County/Municipality This is a request to be the operator in charge at the above facility. This is notification that on I shall no longer be the operator in charge at the above facility. If you have checked this box do not complete Section III and IV of this form* Applicants License No s License Class es Employment Start Date PWS ID Number Your request to operate the above facility as the licensed operator in charge will be considered provided this form is complete in its entirety. NO ACTION WILL BE TAKEN IF DATA AND SIGNATURES ARE MISSING* 1. Have you been to the plant to evaluate the time required to operate the facility efficiently Yes No 2. I will devote hours per week month. 3. Name s license classification s and contact number s of licensed individual responsible and available during your unavailability Name License Class/No* Phone No* STATEMENT FROM REQUESTING FACILITY Please be advised that the facility known as will be utilizing the services of the above applicant as the licensed operator for their system with the following classification s. I acknowledge that will be the licensed individual responsible during the unavailability of the applicant. FOR OFFICE USE ONLY To Applicant Date Recorded From The Licensing and Pesticide Operations This request has been processed and the records updated accordingly. nj. gov/dep/exams SECTION I LICENSED OPERATOR IN CHARGE EMPLOYMENT NOTIFICATION FORM-WASTEWATER Applicant Phone Numbers 1. Home 2. Business Facility Name 3. Emergency Applicant Signature Facility Classification Mailing Address City State Zip Applicant Name please print Home address County/Municipality This is a request to be the operator in charge at the above facility. Home 2. Business Facility Name 3. Emergency Applicant Signature Facility Classification Mailing Address City State Zip Applicant Name please print Home address County/Municipality This is a request to be the operator in charge at the above facility. This is notification that on I shall no longer be the operator in charge at the above facility. If you have checked this box do not complete Section III and IV of this form* Applicants License No s License Class es Employment Start Date PWS ID Number Your request to operate the above facility as the licensed operator in charge will be considered provided this form is complete in its entirety. .