CONTRACTORS STATE LICENSE BOARD 9821 Business Park Drive, Sacramento, CA 95827-1703 Mailing Address: P.O. Box 26000, Sacramento, California 95826-0026
STATE OF CALIFORNIA 1-800-321-CSLB (2752) www.cslb.ca.gov
Application for Hazardous Substance Removal and Remedial Actions Certification
Application Fee: $50. The fee is not refundable once the application has been filed. By law, this fee is retained even if the application is rejected. Attach a money order or a personal, business, certified or cashier’s check payable to the Registrar of Contractors—do not send cash. There is a $10 service charge for each dishonored check. In order for a contractor to engage in hazardous substance removal and remedial actions, the qualifier for the license is required to apply for and pass this certification examination. (See Business and Professions Code Section 7058.7.)
PLEASE TYPE OR PRINT LEGIBLY IN BLACK INK. COMPLETE ALL AREAS OF THIS FORM. 1. BUSINESS NAME (as it currently appears on the records of CSLB) 2. LICENSE NUMBER 3. CLASSIFICATION(S) HELD
4. BUSINESS MAILING ADDRESS number/street or P.O. box
city
state
ZIP code
5. BUSINESS STREET ADDRESS (REQUIRED OR APPLICATION WILL BE RETURNED)
city
state
ZIP code
6. BUSINESS PHONE NUMBER ( )
BUSINESS FAX NUMBER ( )
BUSINESS E-MAIL ADDRESS
7. The applicant for this certification must complete the information below. Show your full legal name, with no initials. If your legal name includes initials only, state so. With the exception of the driver license number, all the information requested below is required.
NAME last first full middle name
RESIDENCE STREET ADDRESS (REQUIRED OR APPLICATION WILL BE RETURNED)
city
state
ZIP code
RESIDENCE PHONE NUMBER ( )
DATE OF BIRTH (MONTH/DAY/YEAR)
SOCIAL SECURITY NUMBER
DRIVER LICENSE NUMBER
On ___________________________ at _____________________________________________________________ ,
DATE CITY/COUNTY/STATE
I certify under penalty of perjury under the laws of the State of California that all statements, answers, and representations in this application, including all supplementary statements attached hereto, are true and accurate, and that I have reviewed the entire contents of this application. Signature of Qualifying Individual _________________________________________________ Print Name _________________________________________________ Signature of Owner, Partner, or Officer _________________________________________________ Print Name _________________________________________________
*app-haz-cert*
1
13A-26 (6/04)
California Contractors State License Board
Application for Hazardous Substance Removal and Remedial Actions Certification—
Instructions
Only those contractors holding the following classifications may apply for this certification: A – General Engineering B – General Building C-12 – Earthwork and Paving C-36 – Plumbing C-61/D-40 – Service Station Maintenance C-57 – Well Drilling Use the following checklist to make sure your application form is complete and accurate before you submit it— incomplete applications will be returned. All applicants must be at least 18 years of age. The contractor’s license must be current and in good standing; if it is not, this application will be rejected. Enclose the $50 application fee—we can’t process your application without it. Make the check payable to the “Registrar of Contractors.” All areas of the application must be completed in black ink. The full business name must be provided. Mail the application and fee to the: Contractors State License Board P.O. Box 26000 Sacramento CA 95826-0026 Need Help? When the CSLB receives your application, they will send you an acknowledgment explaining how to check the status of your application online at www.cslb.ca.gov, or by calling the 24-hour automated phone number, (800) 321-CSLB (2752). Examinations You may be scheduled for the examination as soon as 15 days from the acceptance of this application. A study guide for the examination is available from CSLB online at www.cslb.ca.gov, or by calling the 24-hour automated phone number, (800) 321-CSLB (2752).
(e)(1) A contractor may not install or remove an underground storage tank, unless the contractor has passed the hazardous substance certification examination developed pursuant to this section. (2) A contractor who is not certified may bid on or contract for the installation or removal of an underground tank, if the work is performed by a contractor who is certified pursuant to this section. (3) For purposes of this subdivision, “underground storage tank” has the same meaning as defined in subdivision (y) of Section 25281 of the Health and Safety Code.”
Disclosure of Social Security Number and Federal Employer Identification Number
With the exception of driver license numbers, all information requested is mandatory, including disclosure of social security numbers (SSN), and, if a partnership, the federal employer identification number (FEIN)). Collection of social security numbers is authorized by Business & Professions Code Section 30 and Public Law 94-455 (42 U.S.C.A. 405(c)(2)(C)). Your SSN or FEIN will be used exclusively for the purpose of tax enforcement and/or compliance with any judgment or order for family support in accordance with Family Code, Section 17520, or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state. If you fail to disclose your SSN or FEIN, your application for initial or renewal license will not be processed and you will be reported to the Franchise Tax Board, which may assess a $100 penalty against you. The official responsible for the maintenance of this information is the Registrar of Contractors, Contractors State License Board. The information may be transferred to other government agencies. Individuals have the right to review files or records about them maintained by the agency, unless the records are identified as confidential information and exempted by the Information Practices Act, Section 1798.3. Upon acceptance of an application which meets all conditions as determined by the Registrar of Contractors, the name of the applicant, and the business name and license number of the employer will be placed on the Posting List. The Posting List is available for public inspection in the office of the Contractors State License Board in Sacramento.
Family Support
Family Code Section 17520 authorizes the local child support agency to notify the Department of Child Support Services when there is noncompliance with a family support order or judgment issued by a court of this state. The code requires the Department of Child Support Services to compile this information and distribute it to the specified state agencies (which includes the CSLB). The licensing agencies may be precluded from issuing a license, certificate, or registration to a person on the list until the person obtains a release from the local child support agency.
Notice on Collection of Personal Information CSLB collects the personal information requested on this form as authorized by B&P Code § 30 and CCR 816. CSLB uses this information to identify and evaluate applicants for licensure, issue and renew licenses, and enforce licensing standards set by law and regulation. Submission of the requested information is mandatory. CSLB cannot consider your application for licensure or renewal unless you provide all of the requested information. You may review the records maintained by the CSLB that contain your personal information, as permitted by the Information Practices Act. We make every effort to protect the personal information you provide us, however it may be disclosed in response to a Public Records Act request as allowed by the Information Practices Act; to another government agency as required by state or federal law; or in response to a court or administrative order, a subpoena, or a search warrant. For questions about the Department of Consumer Affairs’ privacy policy or the Information Practices Act, contact the Office of Privacy Protection, 400 R Street, Sacramento, CA 95814, or email privacy@dca.ca.gov. 2 13A-26e (6/04)
Notices to Applicant
Related Laws
Business and Professions Code Section 7058.7 reads, in part: “(a) No contractor may engage in a removal or remedial action, as defined in subdivision (d), unless the qualifier for the license has passed an approved hazardous substance certification examination. . . . (d) For purposes of this section “removal or remedial action” has the same meaning as found in Chapter 6.8 (commencing with Section 25300) of Division 20 of the Health and Safety Code, if the action requires the contractor to dig into the surface of the earth and remove the dug material and the action is at a site listed pursuant to Section 25356 of the Health and Safety Code or any other site listed as a hazardous substance release site by the Department of Toxic Substances Control or a site listed on the National Priorities List compiled pursuant to the Comprehensive Environmental Response, Compensation, and Liability Act of 1980 (42 U.S.C. Sec. 9601 et seq.). “Removal or remedial action” does not include asbestos-related work, as defined in Section 6501.8 of the Labor Code, or work related to a hazardous substance spill on a highway.