Microsoft word - jamestown_ service_provider_application_june2009.doc

THE TOWN OF JAMESTOWN
OWTS SERVICE PROVIDER APPLICATION
June 2009

SECTION A: TYPE OF APPLICATION

New application
Renewal application
This allows service providers to complete First Maintenance Inspections and Routine Maintenance Inspections as required Alternative ISDS Inspector / Maintenance Provider New application
Renewal application
This allows service providers to complete operation and maintenance services on alternative and innovative technologies.
SECTION B: COMPANY INFORMATION

COMPANY NAME :________________________________________________________________________________
COMPANY CONTACT:_____________________________________________________________________________
ADDRESS:________________________________________________________________________________________
__________________________________________________________________________________________________

PHONE:____________________________________________FAX:__________________________________________
E-MAIL ADDRESS:_________________________________________________________________________________

SECTION C: INSPECTOR QUALIFICATIONS

CONVENTIONAL ISDS INSPECTORS (#1 is mandatory)

1. COMPLETION OF THE UNIVERSITY OF RHODE ISLAND COOPERATIVE EXTENSION ONSITE ISDS INSPECTION TRAINING COURSE (INSP100) Completion Date of Course: Month: ___________ Date: _____________ Year: _________________ 2. CURRENT RHODE ISLAND CLASS II OR CLASS III DESIGNER LICENSE LICENSE # ________________________________________________ 3. CURRENT RHODE ISLAND CLASS I ISDS DESIGNER OR INSTALLER LICENSE LICENSE # ________________________________________________
ALTERNATIVE AND INNOVATIVE MAINTENANCE PROVIDERS (1 and 2 are Mandatory)
1. MANUFACTURER CERTIFICATION (PLEASE ATTACH CERTIFICATE OF COMPLETION) NORWECO SINGULAIR ORENCO ADVANTEX AX -20 ORENCO ADVANTEX RX -30 BIOMICROBICS FAST SYSTEM COMPANY CERTIFICATION WAS PERFORMED BY:________________________________________ DATE COMPLETED:_____________________________________________________________________ 2. COMPLETION OF THE FOLLOWING UNIVERSITY OF RHODE ISLAND COURSES: a. INSP100: CONVENTIONAL FIRST MAINTENANCE INSPECTION CLASS DATE COMPLETED:______________________________________________ DATE COMPLETED:______________________________________________ c. INSP200: OPERATION AND MAINTENANCE CLASS DATE COMPLETED:______________________________________________ SECTION D: PROFESSIONAL CONDUCT STATEMENT FOR ISDS INSPECTORS
The Town requires every Town Approved ISDS Inspector to behave with the highest degree of professionalism in while conducting Town required inspections. Inspectors are expected to treat every person they encounter in the work environment with the highest level of honesty, courtesy, respect and consideration. Inspectors are expected to follow the inspection procedures laid out in the State of Rhode Island’s Septic System Checkup Handbook to conduct an honest and accurate representation of the current function of their clients ISDS. If the Town receives written notification of negligent or dishonest reporting on the part of the inspector, the inspector may be removed from the Town’s List of Approved ISDS Inspectors.
SECTION E: INSURANCE INFORMATION
Pease attach certificate of insurance for at least 1 million dollars general liability with completed operations coverage, or
error and omissions with the Town as additional insured.
Insurer: ___________________________________________________________________________________________
Policy #:_____________________________________________________ Expiration Date: ________________________



SECTION F: INSPECTOR CERTIFICATION
I certify that as a Town Approved ISDS Inspector I will conform to the inspection procedures and policies as outlined in the
above document, and understand the Town’s enforcement policy. The application must be signed by each service provider
for your company who will be performing inspections in the communities listed in Part A.
NAME: _________________________________________________________________________ SIGNATURE:________________________________________________ DATE:_____________ NAME: _________________________________________________________________________ SIGNATURE:________________________________________________ DATE:_____________ NAME: _________________________________________________________________________ SIGNATURE:________________________________________________ DATE:_____________ NAME: _________________________________________________________________________ SIGNATURE:________________________________________________ DATE:_____________
CONTACT INFORMATION FOR OTHER RIWIS COMMUNITIES

The Town of New Shoreham
The Town of Charlestown
The Town of North Kingstown
The Town of Jamestown
The Town of Tiverton
Carmody™ - Systems Administrator
P.O. Box 434
DeForest, WI 53532
608-846-0234 Office
608-846-0267 Fax
SERVICE PROVIDER USER APPLICATION FORM
All information must be complete for processing.
APPLICANT MUST COMPLETE THIS BOX AND FAX TO REPORTING AGENT OR 608-846-0267
(PLEASE PRINT CLEARLY)
Installer
Inspector
Designer
Other _________________________________
Name ___________________________________________________________________________________
Company Name ____________________________________________________________________
Address _________________________________________________________________________
City ________________________________________ State ________ ZIP___________________
Telephone # ___________________________________
Fax # _____________________________________
Operating License # _____________________________________________________________________
Email Address____________________________________________________________________
Your Service Territories – State(s), _______ ________ ______ ________ __________ __________ __________ __________ __________ __________ __________ ________________ __________ __________ __________ __________ __________ __________ __________ MUST BE SIGNED BY APPLICANT
I _______________________________ have read and agree to the Carmody Program TERMS OF USE.
To review TERMS OF USE see web site log in page at www.carmodydata.com click on the
ENTER button and look under the Main Menu.
Regulator’s Authorization
Authorized by: ______________________________________________________________ Date: ___________ (Print Name) _______________________________________________________________ Regulator must authorize application before password can be issued.
Carmody Use Only
Your Username & Passwords will be automatically selected and sent to you when application is approved.
Copyright, CDS Holding, Inc. 2001- 2007

Source: http://www.jamestownri.net/pw/wwm/INSP_Application.pdf