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Microsoft Word - Application-individualdoc

By Gloria Ford,2014-01-20 02:13
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Microsoft Word - Application-individualdoc

    BILL RITTER, JR. DEPARTMENT OF LABOR AND EMPLOYMENT Governor Division of Oil and Public Safety LP-Gas Inspection Program DONALD J. MARES th633 17 Street, Suite 500, Denver CO 80202 Executive Director Phone 303/318-8533 Fax 303/318-8488 RICHARD O. PIPER E-mail oil.publicsafety@state.co.us Web http://ops.cdle.state.co.us Division Director

INDIVIDUAL APPLICATION TO ADJUST AND SEAL LP-GAS METERS IN

    COLORADO

     Print or type all information. Individual’s name

    Home Street or P.O. Box mailing City State ZIP address

    Employed by

    Business Cell E-mail phone phone

    List all other states in which the undersigned individual is authorized to adjust LP-Gas meters: Has any state ever rescinded the undersigned individual’s authorization to adjust LP-Gas meters? No Yes (PROVIDE DETAILS IF “YES”)

    List all manufacturers that have authorized the undersigned individual to calibrate and adjust its LP-Gas meters.

    Has any manufacturer ever rescinded its authorization to allow the undersigned individual to calibrate and

    adjust its LP-Gas meters? No Yes (PROVIDE DETAILS IF “YES”)

The undersigned certifies to each of the following:

    1. I have read the attached document entitled Requirements for Calibrating,

     Adjusting, & Sealing LP-Gas Meters in Colorado, and I agree to abide by all

     provisions of this document. ATTACH SIGNED COPY.

2. Documentation exists to verify the licensing or certification by other states or

     meter manufacturers identified above. I will provide this document to the OPS

     upon request.

Signed:_______________________________________________Date:_____________

    Print or type name:_____________________________________Title:_____________

    Subscribed and sworn before me in______________County, State of________________

this____day of______________20____. My commission expires:___________________

Notary Public:____________________________________________________________

? REQUIRED ATTACHMENT:

    ? Signed Requirements For Calibrating, Adjusting, & Sealing LP-Gas Meters in

    Colorado

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