Rev. 6/2019
Wastewater Operator Certification Training Provider Application
Illinois Environmental Protection Agency
1021 North Grand Avenue East P.O. Box 19276 Springfield Illinois 62794-9276 (217) 782-3397
Wastewater Operator Certification Training Provider Application
Mail to: Illinois EPA - Wastewater Operator Certification, BOW/CAS #19, 1021 North Grand Ave. East, PO Box 19276, Springfield, IL 62794-9276
Training Provider or Sponsor
Address
City State Zip
Contact Name
Contact Email Address
Daytime Telephone Number
Confirmation of course approval can be sent by email, fax, or direct mail. Please indicate which method your prefer.
Mail to the address above.
Send by email to this address:
Send by fax to this number:
Training Event Name
Workshops, seminars, and/or conferences should always be considered one-time events unless the subject matter (agenda) stays the same.
Is this training a one-time event? Yes No
If YES, Date(s) of Training:
If NO, what is the frequency/location of the training?:
What best describes the format/type of training that is involved? (Check all that apply.)
Conference/Seminar Classroom (college) Actual Hands-On Operator's Group Meeting/Workshop
ERTC ISAWWA IL Rural Water Regional/Association Group Workshop
If actual hands-on training is involved, please describe:
What general water-related content will this training provide? (Check all that apply.)
Secondary Treatment Preliminary Treatment Primary Treatment
Disinfection Sludge Handling/Application Maintenance
SCADA/Controls Collection Systems Lab Analysis
Chemical Feeding and/or Calculations Pumps Bio-Nutrient Removal
Collecting Samples Clarifiers Regulations/Records
Safety Process Control Water-Related
Activated Sludge Fixed Film Lagoon
Please describe here if nothing above applies or describe any additional content that will be covered in training.
If applicable, please attach any relevant documentation such as an Agenda that will help describe the training.
For this training, I am requesting that
total hours
and/or
minutes
of training credit be issued to all attendees.
(If this training is an extended event covering weeks or months, I request
weeks
or
months
of credit be issued.)
I certify that the above information is true and accurate. I further acknowledge that any person who knowingly makes a false,
fictitious, or fraudulent material statement, orally or in writing, to the Illinois EPA commits a Class 4 felony. A second or
subsequent offense after conviction is a Class 3 felony. (415 ILCS 5/44(h))
Signature: Date:
For Agency Use Only
Approved By: Start Date: End Date: Course ID Number:
