ࡱ> '` lbjbj 7rP5BBBB l3l3l383L3Bf56666c768M9\AAAAAAA$DhnFpA];_7c7;;ABB66ZBK>K>K>;B866AK>;AK>K>zK>64  HE@l3<K>><pB0BK>Fk=FK>FK>P9v:TK>s:D:8999AA=^999B;;;;d&d &4"BBBBBB  JOHN ELIAS BALDACCI GOVERNOR David P. Littell COMMISSIONER STATE OF MAINE DEPARTMENT OF ENVIRONMENTAL PROTECTION RENEWAL APPLICATION FOR LICENSING AS AN ASBESTOS ANALYTICAL LABORATORY Complete all sections of the application either by hand printing in ink or typing in the gray areas. Print out and sign the completed application and mail to Maine DEP with the appropriate application fee. Attach additional sheets as necessary. 1. Applicant:Company Name FORMTEXT  Company Address FORMTEXT  City FORMTEXT  State FORMTEXT  Zip FORMTEXT      Company Phone Number FORMTEXT  e-mail address FORMTEXT  Previous License Number (if applicable): FORMTEXT  Responsible Person: FORMTEXT  Title FORMTEXT      Is the applicant licensed or certified an asbestos laboratory in another state?Yes FORMCHECKBOX No FORMCHECKBOX If Yes, where: FORMTEXT  License or Registration Number: FORMTEXT  2. Laboratory Categories: (Note: if applying for both Air & Bulk, fee is $400.00 only)A) FORMCHECKBOX Air AnalysisC) FORMCHECKBOX Limited Air Analysis (In-House*)B) FORMCHECKBOX Bulk AnalysisD) FORMCHECKBOX Limited Bulk Analyst (In-House*)*NoteLimited to asbestos analytical activities conducted in-house solely for internal company use and not for a third party (individual, business or public entity) 3. RENEWAL REQUIREMENTS: A renewal applicant must provide proof of proficiency, as determined by NVLAP or AIHA, to the Department along with its application. 4. RENEWAL REQUIREMENTS: A renewal application for an Asbestos Analytical Laboratory license must meet the application requirements set forth below and/or submit attesting documentation: A.  FORMCHECKBOX  By signing this renewal application, the applicant hereby confirms that the information, submitted in our original application is currently in effect and unchanged. or  FORMCHECKBOX  Included with this renewal application are any changes to the standard operating procedures, including QA/QC program of our original application. and B.  FORMCHECKBOX  Included with this renewal application is a list of current employees including their dates of expiration of state certification and training accreditation. 5. ENFORCEMENT ACTIONS: Have there been any enforcement actions taken against the company with respect to asbestos activities during the past year? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If YES, provide detailed information on the enforcement action(s) and copies of all correspondence relating to the enforcement action. (Note: Notices of violation are considered enforcement actions.) 6. FEE: The application must include a non-refundable cashiers, certified or company check in the amount of $400 dollars made payable to the Maine Environmental Protection Fund. 7. SIGNATURE: I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED THE INFORMATION SUBMITTED IN THIS DOCUMENT AND ALL ATTACHMENTS THERETO AND THAT, BASED ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING THE INFORMATION; I BELIEVE THE INFORMATION IS TRUE, ACCURATE, AND COMPLETE. I AM AWARE THERE ARE SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING THE POSSIBILITY OF FINE AND IMPRISONMENT. 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