ࡱ> "$ !c bjbjnn e f fM'""W0W0W0W0W0d000k110d34(4447v7D;8$vcxcxcxcxcxcxc$1hjdc9W0"AA7@7"A"AcW0W044xcDDD"ARW04W04vcD"AvcDDB\fb4`tArNafbcc0dafKkBKkbKkW0bH_8|:D<l >_8_8_8ccC_8_8_8d"A"A"A"AKk_8_8_8_8_8_8_8_8_8" /:  APPLICATION FOR CERTIFICATION FOR UNDERGROUND STORAGE TANK INSPECTOR OR UNDERGROUND STORAGE TANK INSTALLER  Maine Board of Underground Storage Tank Installers Department of Environmental Protection 17 State House Station Augusta, ME 04333-0017 Web page:  HYPERLINK "http://www.maine.gov/dep/waste/busti/installerinspector.html" www.maine.gov/dep/waste/busti/installerinspector.html Board Staff: Theresa Scott Office Telephone: (207) 287-7688 Office Fax: (207) 287-7826 Office Location: Ray Building 28 Tyson Drive Augusta, Maine 04333 APPLICATION INSTRUCTIONS Examination/Certification Requirements COMPLETING THE APPLICATION FORM Answer all questions and return the following to this office: Application form. One black and white or color photograph of yourself to scan (Optional) A check or money order for the applicable application and examination fees (shown on fee structure on page 4) made payable to Treasurer, State of Maine *. An experience data sheet for each job listed by the applicant which he/she deems relevant to becoming certified. Three professional reference forms. The forms must be submitted directly to Board staff by the person(s) completing the form(s). Three personal reference forms. The forms must be submitted directly to Board staff by the person(s) completing the form(s). Six (6) reference forms are enclosed. You must submit them to the appropriate persons, and the reference forms must be returned to Board staff. Your application will not be considered complete until all references are received by Board staff. The Boards staff may check police records to verify ethical practice by the applicant. Please note that your application must be signed in the presence of a Notary Public or a Justice of the Peace. To find a Notary Public or a Justice of the Peace in your area, please call the Secretary of States office in Augusta, Maine at (207) 287-3501. All documents become the property of the Board upon submission, and will not be returned. You will be notified as soon as Board staff receives your application. By submitting your application, you will automatically be kept informed of training sessions, examination information, and all pertinent certification information. *Persons who currently hold a valid Master Oil Burner Technician License in Maine are exempted from the application and examination fee for the oil tank installer certificate. A completed application must still be submitted. Please submit a photocopy of your oil burner license together with your application. No fees are waived for applicants applying for the underground tank inspector certificate.  STATE OF MAINE Maine Board of Underground Storage Tank Installers Privileges The Maine Board of Underground Storage Tank Installers offers a number of certifications. Each of these certificates permits different types of work. Certificates offered are as follows: Underground Storage Tank Installer: This certificate permits individuals to install, inspect and remove all types of underground oil storage tanks and facilities. Underground Storage Tank installers may also install underground hazardous substance tanks under the supervision of registered engineers. Field constructed tanks and impressed-current cathodically protected tanks and facilities are excluded, however. Underground Storage Tank Inspector: This certificate permits the tank inspector to conduct the annual tank inspections of underground oil storage facilities required by State law and Department of Environmental Protection rules. Demonstration of third-party cathodic protection tester certification is also required to conduct the cathodic protection tester portion of the annual inspection. Certification by the manufacturers of leak detection equipment is required to annually inspect specific brands and models of equipment. No certificate is required to remove heating oil tanks or other tanks that store fuels that are not classed by the National Fire Protection Association (NFPA) as explosive. The removal of tanks storing explosive fuels such as gasoline and aviation fuel do require certified people. Certification Requirements All certificates require some form of testing and demonstration of field knowledge. All certificates are valid for two (2) years at a time, after which time the certified individual must demonstrate having obtained eight (8) hours of Board approved continuing education credits and pay the appropriate fee. Initial certification is somewhat different for the tank installers than for tank inspectors. Oil Tank Installers: The first step is filing an application with the Board. The Board only certifies individuals; companies or corporations may not be certified. All applicants for oil tank installers certification must take an initial general test. Generally, applicants will apprentice on enough relevant projects to earn 1000 points towards the completion of their apprenticeship. They must complete, under the supervision of a certified tank installer, the installation of a facility used for the distribution of oil or gasoline that includes submersible piping and leak detection for that piping (worth 300 points). They must also perform the removal of an underground gasoline tank (worth 100 points). They then can choose from a number of projects to earn the remainder of their points. If you are applying for a tank installer certificate, please list the name and certificate number of the underground storage tank installer who will supervise your projects. The Board may issue a variance to the apprenticeship requirement if the applicant can demonstrate field experience that equals or exceeds having served an apprenticeship. Following the apprenticeship, the applicant must pass a final examination specific to the class desired. Underground Oil Tank Inspectors. Passage of a single examination is required for certification as an underground oil storage tank inspector. The applicant must demonstrate additional certifications by associations and/or manufacturers to test the cathodic protection or inspect specific brands of leak detection equipment. Fees Underground Storage Tank Installers Initial Fee (includes study guide) $200.00 Variance to Apprenticeship $200.00 Final Examination $250.00 Biennial Recertification $150.00 Persons holding Master Oil Burner (MOB) Technician licenses are exempted from examination and certification fees for underground oil storage tank installer certificates only. Underground Storage Tank Inspectors Examination Fee (with study guide) $250.00 Certification Fee $150.00 Recertification $150.00 Examination Process Final examination instructions will be emailed approximately one week prior to the examination to each individual who has filed an application with the Board. The instructions will detail the date, time, location and general instructions for the examination. What to Bring to the Examination Underground Tank Installer examinees have as much time as you need to take the initial examination, which is closed book. The Final examination are limited to a four (4) hour time limit for the final examination, which is open book. Tank Inspector examinees have a two and one half (2 1/2) hour time limit to take the examination since it is open book. Tank Inspector applicants and Tank Installer applicants taking the final examination may also bring the reference materials included in the study materials that were provided. Only pre-registered candidates will be admitted to the examination. No walk-in applicants will be admitted. An applicant who does not appear for the scheduled examination will forfeit the examination fee. An applicant who arrives after the examination supervisor has started the instructions may not be admitted. Description of Examinations The examination for the initial tank installer examination is closed book and multiple choice. Some questions may refer to a figure drawing, table or chart in the examination booklet. The tank inspector examination and the final tank installer examination are open book and multiple choice. The applicant may use the reference materials provided with the study guide for the examination, but may not use the study guide itself. Scoring Information The initial tank installer examination includes 100 questions, and the final tank installer examination has 125 questions. The tank inspector examination includes 104 questions. A minimum score of at least 80% is required for passage for all examinations. Most commonly, these are written examinations. An application can request an oral examination if good cause exists as to why they could not take a written examination. Your score is based on the number of questions you answer correctly. You will not be given credit for any question that has been answered incorrectly, left blank or has more than one answer marked. Be sure to mark an answer for each question. Your examination score is confidential and will NOT be released to anyone other than you and the Board. Your score will be emailed or mailed to you approximately ten (10) business days after your examination. Applicants will be notified by regular mail only. No examination scores will be given over the telephone. A candidate who does NOT pass will be notified when a new examination date is set. The retake examination fee is $100.00 for all examinations and do not need new study materials. Please notify Staff of the Board of any change of address, phone number or email address. Candidates with Special Needs If a physical disability or other special need prevents you from taking the examination under normal conditions, please fill out the accommodation request form. Submit medical documentation of your disability to Staff along with your accommodation request form and appropriate fee. The Board will review your request at their next regularly scheduled meeting. Examination Dates, Deadlines and Locations Pease contact Staff at 207-287-7688 for examination information. Examinations are administrated in the Augusta, Maine area. Examination Review At their request, applicants will be provided the opportunity to review the questions they answered incorrectly along with the correct answers. That review must be accomplished by appointment at the Boards offices. Examination questions may not be retained or copied by the applicant. No other person may review an applicants examination. Please contact Staff for further information. UNDERGROUND STORAGE TANK INSTALLER OR INSPECTOR EXAMINATION APPLICATION Place ID Picture Here (Optional)STATE OF MAINE DEPARTMENT OF ENVIRONMENTAL PROTECTION BOARD OF UNDERGROUND STORAGE TANK INSTALLERS 28 TYSON DRIVE, 17 STATE HOUSE STATION AUGUSTA, ME 04333-0017 TEL: (207)287-7688 FAX: (207)287-7826 Office Use Only Application Received: _________________ Check Number: _____ Check Amount:______  This application is public record for purposes of Maines Freedom of Access Law, 1 MRSA 401, et seq. Public records must be made available to any person upon request. Information that you supply as part of this application (except your Social Security number) is public information. Other licensing records to which this information may later be transferred are also considered public records. Where permitted by law, your name, license number, mailing address and other information listed on this application may be posted on the States website.The following statement is made pursuant to the Privacy Act of 1974, Section 7(B). Disclosure of your social security number is mandatory. Solicitation of your social security number is solely for tax administration purposes pursuant to 36 M.R.S.A. Section 175 as authorized by the tax reform act of 1976 (42 U.S.C. Section 405(C)(2)(C)(I)). Your social security number will be disclosed to the State Tax Assessor or an authorized agent for use in determining filing obligations and tax liability pursuant to Title 36 of the Maine Revised Statutes. No further use will be made of your social security number and it shall be treated as confidential tax information pursuant to 36 M.R.S.A. Section 191. APPLICATION IMPORTANT: You must submit your examination fee with this application. NOTE: The application fee is non-refundable. The study guide will be mailed to you upon receipt of the study guide examination fee, made payable to Treasurer, State of Maine. Please indicate: Examination Study Guide: r Yes r No TYPE OF EXAMINATION r Underground Oil Storage Tank Installer r Underground Oil Storage Tank Inspector including; r Specific Manufacturer Certification r Cathodic Protection Testing  Name of Applicant: Email Address: Home Address: City:State: Zip Code:County: Home Telephone:Business Name of Applicant: Business Address: City:State:Zip Code: County:Business Telephone: Please indicate where you wish to receive mail sent by the Board:  FORMCHECKBOX  Home Address  FORMCHECKBOX  Business Address Social Security Number: If you are applying for an underground storage tank installers certificate, please list the name and certificate number of the installer who will supervise you: Name:_________________________________________ ID Number: _______________________________ Place of Birth: ______________________________ Date of Birth: _________/__________/___________ Sex:  FORMCHECKBOX  Male  FORMCHECKBOX  Female Do you hold any other type of professional registration or license from a governmental body in or out of the State of Maine (i.e.: electricians or plumbers license)?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Type of License:_____________________________________________________________________________ Issuing Agency:__________________________________________ State:______________________________ Date Issued:__________________ Date Expired:____________________ Has this license ever been revoked or suspended?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes, provide appropriate dates of suspension or revocation. Date Issued:__________________ Date Expired:____________________  Do you hold any other type of professional registration or license from a governmental body in or out of the State of Maine (i.e.: electricians or plumbers license)?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Type of License:_____________________________________________________________________________ Issuing Agency:__________________________________________ State:______________________________ Date Issued:__________________ Date Expired:____________________ Has this license ever been revoked or suspended?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes, provide appropriate dates of suspension or revocation. Date Issued:__________________ Date Expired:____________________  TRAINING AND EDUCATION Please complete this section by listing all tank installation, inspections & construction safety classes, seminars or courses you have completed. TITLE PRESENTED BYDATE(S)           EMPLOYMENT RECORD Please list your professional experience related to tank Installation, removal or inspection. Begin with present position and proceed to prior employers. If more space is needed, attach an 8 x 11 sheet of paper to this application. PRESENT OR LAST EMPLOYER:  From: _____/_____/_____ To: _____/_____/_____COMPLETE ADDRESS: TELEPHONE NUMBER:YOUR TITLE: NAME OF SUPERVISOR: DETAIL OF WORK PERFORMED: REASON FOR LEAVING OR SEEKING OTHER EMPLOYMENT: EMPLOYER #2  From: _____/_____/_____ To: _____/_____/_____COMPLETE ADDRESS: TELEPHONE NUMBER:YOUR TITLE: NAME OF SUPERVISOR: DETAIL OF WORK PERFORMED: REASON FOR LEAVING OR SEEKING OTHER EMPLOYMENT: EMPLOYER #3  From: _____/_____/_____ To: _____/_____/_____COMPLETE ADDRESS: TELEPHONE NUMBER:YOUR TITLE: NAME OF SUPERVISOR: DETAIL OF WORK PERFORMED: REASON FOR LEAVING OR SEEKING OTHER EMPLOYMENT: EMPLOYER #4  From: _____/_____/_____ To: _____/_____/_____COMPLETE ADDRESS: TELEPHONE NUMBER:YOUR TITLE: NAME OF SUPERVISOR: DETAIL OF WORK PERFORMED: REASON FOR LEAVING OR SEEKING OTHER EMPLOYMENT: THIS SECTION APPLIES TO APPLICANTS FOR UNDERGROUND STORAGE TANK INSPECTOR CERTIFICATION ONLY If you are or were certified to test cathodic protection systems by a professional organization such as NACE International, provide the following information about your certification and enclose a copy of your most recent certificate or identification card. Demonstration of cathodic protection tester certification is required in order to conduct cathodic protection tests. Certifying AgencyCertification TitleCertificate NumberDate CertifiedExpiration of Certificate  List Manufacturer Certificates and Training for the Operation and Testing of Leak Detection Equipment (use additional space if necessary). Enclose copy of your most recent certificates or identification cards. If a manufacturer certification program is available it is required for an inspector to complete before he or she can inspect that equipment. Manufacturer Model of EquipmentCertification Level (If applicable)Date CertifiedExpiration Of Certificate                 I HEREBY CERTIFY THAT THIS APPLICATION CONTAINS NO WILLFUL MISREPRESENTATION OR FALSIFICATION AND THAT THE INFORMATION GIVEN BY ME IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND THAT MY ANSWERS MAY BE VERIFIED AND THAT I MAY BE DECLARED INELIGIBLE FOR A LICENSE IF THE INFORMATION CONTAINED HEREIN, UPON INVESTIGATION, IS FOUND TO BE MISREPRESENTED OR FALSIFIED. ___________________________________________________ Signature of Applicant ___________________________________________________ Date THIS SECTION MUST BE COMPLETED BY A NOTARY PUBLIC State of ___________________________ County of _________________________ The above named ___________________________________________ personally appeared before me and being duly sworn according to law deposes and says that the answers set forth in this application are complete to the best of his/her knowledge and belief. Sworn and subscribed to before me this __________________ day of ___________________ 20 ______________. 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