Southern Illinois Water Operators Association: 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

Name of Company or Organization Providing Training

Course Training Name

Date(s) of Training

Hours/Minutes

City (Where Training Occurred)

 

*Course ID Number

Name of Company or Organization Providing Training

Course Training Name

Date(s) of Training

Hours/Minutes

City (Where Training Occurred)

 

*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))

 


Signature:_                                                                                                      


Date:_                                     


Daytime Phone: (           )                                       




Copyright 2009 web hosting services by 2mHost.com