State of New Mexico Environment DepartmentEnvironmental Health Bureau

Liquid Waste Program

Septage Pumper Application Form

Name of Company

!115

Mailing Address 3005 N Canton Aye, Farrnington, NM 87401

Phone Number e oEmailAddress cjse4a tJzovHave you completed the NAWT Vacuum Truck Technician Training Certification Program or acomparable program?You must demonstrate familiarity with the applicable regulations and demonstrate competence in locating andexposing septic tanks, measuring septic sludge and scum levels, the complete pumping of septic tank sludge, NOmaintenance of pumping equipment in a sanitary condition and prevention of pathogen transmission andpreparation of an appropriate safety plan for normal operationsNMED considers completion of the National Association of Wastewater Technicians (NAWT) Vacuum TruckTechnician_Training_Certification_Program_demonstrating_competence_for_these_requil-emnents.Do you understand tha tyou must maintain your equipment to ensure no sewage spill occurs during ES NOtransport or storage and that your employees or the public are not subject to a hazard to public health?Do you have a written contingency plan for spill abatement and shall have the equipment and supplies (y NOneeded_to_abate_spills_onsite_during_each_pumping_operation?Do you understand that there must be a Certified Septage Pumper on-site any time that a septic tank is NOpumped?List all the facilities that you use for the septage disposal. Upon request you may be asked to provide copies of any permits orlicenses issued by the owner of the disposal facility to the septage pumperSeptage Disposal Facilities that I use: e.- vc c. 4 4 e i . . - rc 1 isi ie >

By signing below, I akcnowledge that I have read the Liquid Waste Disposal and Treatment Regulations and I understand thesections of the regulations that pertain working as a septage pumper.

(7(et.Septage Pumper Name Printed Septage pumper Signature Date

Please Complete this Application and attach your NA WT Vacuum Truck Technician Training certificatioiz and Send toMichael Broussard, EHB Liquid Waste Specialist, 2450 Cain mo Edward Ortiz, Santa Fe, NM 87505; Fax 505-827-1839

For more information please contact Michael Broussard at Michael.Broussard@state.nm.us or 505-476-0125Once you are approved by NMED your name will be added to the Septage Pumper list on the Liquid Waste Programs website

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2540 QEamino Qbbarb QrtIauta ffe, fIll 87507

jone (505) 827-1840 ffax (505) 827-1839 Qtabinet ecretarp.nmenb.tate.nm.uZ ittcD Vlonite

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EertIficatc Qi( 3?eitrationCertificate No. D15 13338

Ianjam, .McnnIs hereby registered as a Septage Pumper in accordance with NMAC

20.7.3.904D.

The registered individual above is required to meet the following requirements:o Septage pumpers shall demonstrate familiarity with applicable regulations and demonstrate competence

in locating and exposing septic tanks, measuring septic sludge and scum levels, the complete pumping ofseptic tank sludge, maintenance of pumping equipment in a sanitary condition, prevention of pathogen

transmission and preparation of an appropriate safety plan for normal operations.o Septage pumpers shall maintain his or her equipment to ensure no sewage spills occur duringtransport or storage and that his or her employees or the public are not subjected to a hazard to public

health.o Septage pumpers shall have a written contingency plan for spill abatement and shall have the

equipment and supplies needed to abate spills onsite during each pumping operation.o Septage pumpers shall notify the department of the facilities they use for the septage disposal and shall

provide the department with copies of any permits or licenses issued by the owner of the disposal facility tothe septage pumper.

o 20.7.3.306 STANDARDS; SEPTAGE: Disposal of septage shall occur only at a permitted facility withthe knowledge and consent of the facility owner, and shall not cause a hazard to public health nor degrade abody of water. Transport and disposal of septage shall be in conformance with applicable federal, state andlocal regulations. Septage pumpers shall keep customer invoices and disposal records for three years and

shall, upon written request by the department, make such records available to the department forinspection.

Registered this day 18 May 2015

+lic(jact rottir1jjF11Q iiiiroitintnti1 )ca1tIj 1trciu1

uSana fflarti,ieabernor

3loljii . iTITCIJClieutenant obernor

LIgtiili Waste peti1It