Permission to Release Contact Information by trevorbowman


									Permission to Release Contact Information

The Idaho Public Records Law, Section 9-338 and 9-348 prohibits the Department of Environmental Quality (DEQ), as a public agency from distributing or providing a mailing list or a telephone number list of licensed operators, UNLESS those individuals on the list have first given their permission for their personal information to be released. If you are planning to contract your services to operate a public wastewater system or systems beyond your home system or wastewater system place of employment then you must fill out the name/address/telephone section below, and mark YES. If you hold multiple licenses and want to contract your services for systems that match each license class, then please fill in every class and license number for which you want to be able to contract your services. Then sign and return this document to the Idaho Department of Environmental Quality. DO NOT RETURN THIS FORM UNLESS YOU ARE GOING TO MAKE YOUR SERVICES AVAILABLE BY CONTRACT to public wastewater systems other than your home system and want that information made available to the public.

Operator Name (Please Print) Operator License Class (es) & Corresponding License Number(s)

Telephone Number Email Address

Cell Phone Number

Mailing Address City State Zip *** Yes I give permission to the State of Idaho to release my name, telephone number & mailing or email address for purposes of contracting my services to operate a wastewater system or systems beyond my home system.

_________________________________________ Signature of Operator Date

Please return this completed, signed form to DEQ 1410 N. Hilton, Boise, ID 83706, Attention: Belinda McFarland. Make a copy of this completed form for your files.

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