Page 1 of 3 For ADEQ OFFICE USE ONLY Test Location: ADEQ: 8:30am / 1:00pm WWL(s) Renewed? YES / NO OTHER: If No: date contacted: by: Test Date: Date app rcvd @ ADEQ: Test Score: PASS / FAIL Prepaid Fee: $40 exam $20 re-exam Graded by: Approved by: for Exam: I II III IV B A Date: ADEQ Wastewater License Exam ApplicationThis application is submitted pursuant to Arkansas Code Annotated § 8-5-201 et seq., and Arkansas Pollution Control & Ecology Commission Regulation 3. All Applicants must INITIAL each statement, acknowledging that you have read and fully understand each statement: I understand that my FULLY COMPLETED APPLICATION must be received and EXAM FEE(s) PAID IN FULL to ADEQ no less than five (5) business days prior to the desired exam date. (NOTE: Class IV application, additional documents, and fee payment are due twenty (20) business days prior to exam.) I understand that submission of an incomplete application, including an application that has not been paid in full by the deadline, will result in the examinee being barred from testing on the requested date. Qualified applicants with disabilities, as defined in the Rehabilitation Act of 1973 or the Americans with Disabilities Act of 1990, may request any needed reasonable accommodations to participate in the licensing process. Please PRINT CLEARLY (use Black or Blue Ink only – no pencil) Today’s Date: Exam Date: Location: If testing at ADEQ, what time? Select one: 8:30am / 1:00pm Is this a Re-Test? NO YES - Date of previous exam: (must be at least 90 days prior to requested exam date) Complete Each of the following: Current Wastewater License # or I do not currently hold a Wastewater License. Social Security Number (PRINT CLEARLY): - - (Required by Act 1163 and to be reported to AR Office of Child Support Enforcement) Name (PRINT CLEARLY): Home Mailing Address: City: State: Zip Code: Home Phone # ( ) - Cell/Other Phone # ( ) - Employer Name: Work Mailing Address: City: State: Zip Code: Work Phone # ( ) - Alternate Phone # ( ) - Email (recommended): Email addresses are used for ADEQ Wastewater Operator Licensing correspondence only. Training (select one): I have Pre-Registered with ARWA or AETA for the following classroom course: I have taken the appropriate Online Course and have attached a copy of my Certificate of Completion. Other Training (explain): How many Total Training Hours are currently documented for you on ADEQ’s website? What License Level are you testing for? (select one): Municipal License (select ONE): I II III IV (additional Class IV exam requirements apply – see Page 3 of application) Industrial License (select ONE): Basic Advanced
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II III IV B A ADEQ Wastewater License Exam Application · Page 2 of 3 Application Fee (select one): Exam - $40.00 per Application (initial fee per license level attempted – re-test
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Page 1 of 3
For ADEQ OFFICE USE ONLY
Test Location: ADEQ: 8:30am / 1:00pm WWL(s) Renewed? YES / NO
OTHER: If No: date contacted: by:
Test Date: Date app rcvd @ ADEQ: Test Score: PASS / FAIL
Prepaid Fee: $40 exam $20 re-exam Graded by:
Approved by: for Exam: I II III IV B A Date:
ADEQ Wastewater
License Exam Application
This application is submitted pursuant to Arkansas Code Annotated § 8-5-201 et seq., and Arkansas Pollution Control & Ecology Commission Regulation 3.
All Applicants must INITIAL each statement, acknowledging that you have read and fully understand each statement:
I understand that my FULLY COMPLETED APPLICATION must be received and EXAM FEE(s) PAID IN FULL to ADEQ no less
than five (5) business days prior to the desired exam date. (NOTE: Class IV application, additional documents, and fee payment are due
twenty (20) business days prior to exam.)
I understand that submission of an incomplete application, including an application that has not been paid in full by the deadline, will
result in the examinee being barred from testing on the requested date.
Qualified applicants with disabilities, as defined in the Rehabilitation Act of 1973 or the Americans with Disabilities Act of 1990,
may request any needed reasonable accommodations to participate in the licensing process.
Please PRINT CLEARLY (use Black or Blue Ink only – no pencil) Today’s Date:
Exam Date: Location: If testing at ADEQ, what time?
Select one: 8:30am / 1:00pm
Is this a Re-Test? NO YES - Date of previous exam: (must be at least 90 days prior to requested exam date)
Complete Each of the following:
Current Wastewater License # or I do not currently hold a Wastewater License.
Social Security Number (PRINT CLEARLY): - - (Required by Act 1163 and to be reported to AR Office of Child Support Enforcement)
Name (PRINT CLEARLY):
Home Mailing Address:
City: State: Zip Code:
Home Phone # ( ) - Cell/Other Phone # ( ) -
Employer Name:
Work Mailing Address:
City: State: Zip Code:
Work Phone # ( ) - Alternate Phone # ( ) -
Email (recommended): Email addresses are used for ADEQ Wastewater Operator Licensing correspondence only.
Training (select one):
I have Pre-Registered with ARWA or AETA for the following classroom course:
I have taken the appropriate Online Course and have attached a copy of my Certificate of Completion.
Other Training (explain):
How many Total Training Hours are currently documented for you on ADEQ’s website?
What License Level are you testing for? (select one):
Municipal License (select ONE): I II III IV (additional Class IV exam requirements apply – see Page 3 of application)
Industrial License (select ONE): Basic Advanced
Page 2 of 3
Application Fee (select one):
Exam - $40.00 per Application (initial fee per license level attempted – re-test fee applies for retaking a failed exam)
Re-Test - $20.00 per Application (re-test date must be at least 90 days after failed exam)
Payment Option (select one):
Invoice me for an Online Credit Card Payment of the applicable fee. (ADEQ accepts Visa, MasterCard, Discover, American Express,
and state-issued P/Cards. Minimal service charge applies to all credit card payments.) Applications can be sent to ADEQ’s Licensing Staff Email:
[email protected]. Email my invoice to (required if box is checked):
I have enclosed a Check / Money Order with this application for the appropriate fee selected above. (Make payable to:
ADEQ-WWL and Mail To: ADEQ / Attn: WWL / 5301 Northshore Drive / North Little Rock, Arkansas 72118)
Bill me using PO#: (This option is only available to State or Corporate offices.)
Employment Background: I currently have total years of Water/Wastewater Experience. (If “0” skip to next section)
Only list experience DIRECTLY related to Treatment System Operation, Maintenance, and/or Management. Include job duties for each specific
position held. Attach additional information if required or necessary for clarification. Incomplete or vague job descriptions will not be accepted.
Dates of Employment Current/Most Recent Employer:
From: To: Company:
(Month/Year) (Month/Year) Address:
Supervisor's Name: Contact#:
Below, describe all job duties (not job titles) directly related to wastewater treatment. (Any duties indirectly related to wastewater may be listed for consideration, separately, at the bottom of this page.)
Dates of Employment Previous Employer #1:
From: To: Company:
(Month/Year) (Month/Year) Address:
Supervisor's Name: Contact#:
Below, describe all job duties (not job titles) directly related to wastewater treatment. (Any duties indirectly related to wastewater may be listed for consideration, separately, at the bottom of this page.)
Dates of Employment Previous Employer #2:
From: To: Company:
(Month/Year) (Month/Year) Address:
Supervisor's Name: Contact#:
Below, describe all job duties (not job titles) directly related to wastewater treatment. (Any duties indirectly related to wastewater may be listed for consideration, separately, at the bottom of this page.)
Please use the following space to list any INDIRECT (water-related) training you wish to submit for consideration of exam qualification: