Free 45703.pdf - Indiana

APPLICATION FOR RADON TESTER/MITIGATOR CERTIFICATION
State Form 45703 (R2/11-99) Approved by the State Board of Accounts 1994

INSTRUCTIONS: 1. This is the radon certification application necessary to satisfy the requirements of 410 IAC 5.1-1-22. You must be certified before you test, analyze or mitigate for radon-222 in Indiana. Submit the complete and accurate application, the appropriate fee(s) and proof of RPP listing to be considered for certification. See the Indiana Radon Rule (410 IAC 5.1) for additional information. 2. Type or clearly print all information. 3. Make personal check or money order payable to: Indiana State Department of Health. (CORPORATIONS MUST SUBMIT SEPARATE CHECKS FOR EACH APPLICANT.) 4. Send the completed form to: Indiana State Department of Health, ATTN: Cashiers Office, Indoor and Radiological Health, 2 North Meridian, Indianapolis, IN 46204-3003. 5. Allow 3 to 6 weeks for processing. You will receive a letter from the Indoor and Radiologic Health program indicating whether the application has been accepted or rejected. 6. If you have any questions, call AC 317/233-7147 and ask for the Radon Coordinator.

Type of Certification Desired:

Check all that apply:
Radon Laboratory Tester Primary Radon Tester Fee: $100.00 Fee: $100.00 Secondary Radon Tester Radon Mitigator Fee: $100.00 Fee: $100.00

Individual Information*:
Last Name: Address: City: Home Phone Number: State: 9 Digit Zip Code Mandatory: First Name: M.I.:

*If this individual is applying for Radon Laboratory Tester and/or Radon Mitigator Certifcation, the individual must be a full-time employee or employer who shall be responsible for all laboratory testing and/or mitigation activities (as outlined in 410 IAC 5.1-1-24, 5.1-1-26).

Business Information:
Business Name: Address: City: State: Business Phone Number: 9 Digit Zip Code Mandatory:

President or Chief Executive Officer
Last Name:

Business Fax Number: First Name: M.I.:

Radon Proficiency Program (RPP) Information (Complete all that apply):
RPP I.D. Number for Residential Measurement: RPP I.D. Number for Analytical Measurement: RPP I.D. Number for Residential Mitigator:

Enclose a copy of your RPP Photo I.D. Card. Also, if applying for Primary Radon Tester or Radon Laboratory Tester, enclose a copy of your Device Performance Test Report (Listing Letter).

Continued on Other Side

Radon Measurement Services: If you are applying for Primary Radon Tester, Secondary Radon Tester, or Radon Laboratory Tester, list the specific type of detector(s) you're using and list the name of the state certified lab analyzing the detector(s) (i.e. "femto-TECH 510 - self analyzed", "charcoal canisters and electret ion chamber detectors - analyzed by X Laboratories").
Type of Service Provided:

Provide Proof:
A. Provide a photocopy of your RPP Photo I.D. card. Also, if you are applying for Radon Laboratory Tester or Primary Radon Tester, enclose your RPP Listing Letter B. If the Radon Laboratory Tester and/or Primary Radon Tester is using a radioactive source for calibration, list the Indiana State Department of Health Radioactive Materials Registration Number

C. If you are applying for Radon Laboratory Tester Certification you must:
i. Provide Proof of a bachelor's degree from an accredited university or college in the physical sciences or engineering or related field

OR
ii. Provide proof of a minimum of two years full-time experience in radiation measurement

Rad. Mat. Reg. #:

For Recertification:
Follow the instructions in this section only if the individual has been certified before with the Indiana State Department of Health in any category. Provide proof of continuing education that was completed within the prior two (2) years and was obtained as follows: At least six (6) contact hours of continuing education from a radon course. Provide written confirmation of attendance, signed by the course instructor or the designee

OR

Full-time employment for the prior two (2) years in any category of certification. Provide written confirmation of full-time employment signed by the business owner or chief executive officer of the business which employed the individual

AND Provide proof of current listing with the RPP. Previous Indiana Certification Number(s):

Check here if applying for recertification

Signature and Notarization: By signing this application, I certify that the information provided in and with this application is complete and accurate to the best of my knowledge, and I agree to supply the ISDH with data regarding testing and mitigation on request. I have also read and agree to adhere to the [Check the appropriate category(s)]: EPA's "Indoor Radon and Radon Decay Product Measurement Device Protocols" EPA's "Radon Mitigation Standards"

(This will satisfy the requirements as outlined in 410 IAC 5.1-1-23, 5.1-1-24, 5.1-1-25, and/or 5.1-1-28.) Signature: Date: Printed Name: State of: County of:
County in which notorized

Title

Place Seal Here

Subscribed and sworn to before me this Signature of Notary:

day of

My commission expires:

Printed Name of Notary

If you move, you must notify the Indiana State Department of Health of your new address. Failure to do so will result in a delay in certification
Before you mail your application:
1. Have all questions on the application been answered? 2. Is your application signed and notarized? 3. Have you enclosed your certification fee? 4. Have you enclosed a copy of the appropriate documents? 5. Have you enclosed a copy of your diploma (if applicable)? 6. Have you enclosed your proof of full-time experience (if applicable)?

Omission of any one of the required documents or incomplete or erroneous information will result in your application being returned to you and a delay in certification.