Wastewater Operator Continuing Education Credit Report {51139}

WASTEWATER OPERATOR CONTINUING EDUCATION CREDIT REPORT State Form 51139 (R / 1-06) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT To ensure proper credit, the wastewater approval number MUST be provided. Training Course Approval Number: Technical Contact Hours Earned: General Contact Hours Earned: INSTRUCTIONS In accordance with 327 IAC 5-22-17(c), the training provider must submit this form within thirty (30) days of the conclusion of the wastewater treatment continuing education course. Mail the completed form to: Wastewater Continuing Education Coordinator Indiana Dept. of Environmental Management 100 N. Senate Ave - Mail Code 65-42 Indianapolis, IN 46204-2251 - Incomplete forms will be returned to the training course provider for completion and resubmittal to IDEM. - Partial course credit shall not be given to instructors, speakers, or students participating in less than a complete wastewater treatment continuing education course. - The training provider must retain a copy of this form for their records for a five (5) year period following the presentation of each wastewater treatment continuing education course. - Training providers are encouraged to provide a copy of the completed and signed credit reporting form to the certified operator attending the entire wastewater operator continuing education course. CERTIFIED OPERATOR INFORMATION 1. NAME: 2. ADDRESS (number and street): City: State: ZIP code: Telephone number: Work: Home/Cell: Email Address: Check here if this is an address change __________ COURSE INFORMATION 3. NAME OF TRAINING COURSE: 4. NAME OF ORGANIZATION SPONSORING COURSE: 5. DATE(S) ATTENDED: 6. LOCATION ATTENDED: 6. TOTAL NUMBER OF CONTACT HOURS ATTENDED BY CERTIFIED OPERATOR AND VERIFIED BY INSTRUCTOR AND TRAINING COURSE PROVIDER: Technical Contact Hours: General Contact Hours: I, the undersigned, certify under penalty of law that this document (and any attachments) were prepared under my direction or supervision and that the information submitted is, to the best of my knowledge and belief, true, accurate, and correct. I also understand that any omissions or misrepresentations may result in the denial of continuing education credit for this course. 8. SIGNATURE OF INSTRUCTOR: 9. PRINTED NAME OF INSTRUCTOR: 10. SIGNATURE OF CERTIFIED OPERATOR: 11. PRINTED NAME OF CERTIFIED OPERATOR: 12. CONTINUING EDUCATION CREDIT HOURS ARE TO BE APPLIED TO: Operator certification number: Class: Expiration date: Operator certification number: Class: Expiration date: American LegalNet, Inc. www.FormsWorkflow.com