28.1.2019

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    Southern Illinois Water Operators Association

                 One Mission, One Purpose, One Passion

    IEPA Blank Form

    Illinois EPA Operator Certification

    BOW/CAS#191021 North Grand Avenue East, PO Box 19276chemas-microsoft-com:office:office" />

    Springfield, Illinois 62794-9276         Telephone 217-785-0561

    OPERATOR TRAINING SUBMISSION FORM

    *Course ID Number

    Date(s) of Training

    *Course ID Number

    Date(s) of Training

    Name of Company or Organization Providing Training

    Hours/Minutes

    Name of Company or Organization Providing Training

    Hours/Minutes

    City (Where Training Occurred)

    City (Where Training Occurred)

    Course Training Name

    Course Training Name

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    *Course ID Number

    Name of Company or Organization Providing Training

    Course Training Name

    Date(s) of Training

    Hours/Minutes

    City (Where Training Occurred)

    *You must include Course ID Number or form will be returned

    I certify that the above information is true and accurate and that I have successfully completed the above listed training. I understand that proof of training records must be maintained by me for a period of four years. I further acknowledge that falsification of this form or any form used in the certificate renewal process may result in denial of certificate renewal or restoration and is a cause of certificate revocation and/or suspension. 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))

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    Last modification: 03/03/14 12:00:00

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