NHDES-S-00-001
Professional Contacts Listing Form
Oil Remediation and Compliance Bureau
Voluntary Form
This is a voluntary form. Please read these directions completely. Failure to provide a complete and accurate form can result in your company not being posted to NHDES’ website Service Provider Listings.
Reasons to Complete and Submit the Form
Your company services are posted onto the NHDES website under: Waste Management Division Activity Reports and Service Provider Listings.
NHDES receives numerous inquiries regarding what companies can provide what services. We direct them to the NHDES website listings. It may be a valuable resource to your company since it is viewed by those looking for services.
NHDES also uses the provided contact information to update employees on current regulations and various guidance documents when needed as well as communicate technical reviews to your employees.
When to Update Your Contact Information
Service Providers should verify contact information regularly and provide updates when needed, such as changes with staff, email addresses, website links, company name and/or location, license renewals, etc.
The database will remove your contact information from the NHDES website Service Providers listing after a 30-day lapse in any license expiration date (employee or company). You must keep that information current if you would like the general public to have access to your contact information.
Complete and Submit the Form
You are welcome to update your company and employee information as often as you want. The form is completed in four parts:
1. Company Information: The main contact information and whether or not your company is NH Certified/Licensed to complete certain services.
2. Company Services: Where you would like your business information to be listed on the website.
3. Licensed/Certified Employees: For employees with specific licenses and/or certifications that is required in order for your company to be posted to the website services provider listings.
4. Other Employee Contacts: Where you would list all any employee(s) you would like included in our technical and regulatory email updates. Include as many employees you want.
Once you have completed the attached Professional Contacts Listing form, please submit to:
NHDES, Waste Management Division
Oil Remediation & Compliance Bureau
PO Box 95
Concord, NH 03302-0095
OR you may email it to:
Company Information:
Company Name:Office Mailing Address:
City/Town: / State: / Zip:
Phone#:
Fax#:
Company Email:
Company Web Site: / www.
Certified Professional Engineering Business Organization: / Check: Yes____ (or) No______
Cert # Expiration Date:
Licensed Asbestos Disposal Site Contractor: / License# Expiration Date:
Company Services:
Place a check mark next to the service(s) provided by your company and the list(s) you wish to be included on. Current License/Certification required.
AST Design Engineer (Requires NH Licensed Professional Engineer.)AST Installer and Maintenance Company (ICC AST Installation/Retrofitting Certification required.)
AST Interior Inspector (Requires either an API 653, STI Certification or a NH Licensed Professional Engineer.)
AST/UST Stage II Vapor Recovery Tester
AST/UST Tester
(Certification requirements specific to type of work being performed to include: ICC UST Tank Tightness Certification and/or Cathodic Protection Certification, NACE Certification, and some work may require a NH Licensed Electrician. Specific manufacturers also may require certification for their equipment.)
Asbestos Disposal Site Contractor or Worker
(Requires NHDES Asbestos Disposal Site Contractor License or Worker Certification.)
Remedial Management Company (Companies that manage and oversee remedial contractors.)
Remedial Contractor (Companies that perform excavation activities for installation of remedial equipment.)
Site Investigation and Remedial Design Consultant
(Requirements specific to type of work being performed to include: NH Professional Geologist or NH Licensed Professional Engineer.)
UST Design Engineer (Requires NH Licensed Professional Engineer.)
UST Installation and Maintenance Company
(Requires ICC UST Installation/Retrofitting Certification or NACE Certification, and some work may require a NH Licensed Electrician. Specific manufacturers also may require certification for their equipment.)
UST Decommissioning Contractor (Requires ICC UST Decommissioning Certification.)
Note: Engineering Businesses must have a current NH Professional Engineering Business Organization Certification and a NH Certified PE in employment. For PE sole proprietor the business certification is not required.
Telephone: (603) 271-3899 Fax: (603) 271-2181 TDD Access: Relay NH 1 (800) 735-2964
PO Box 95, Concord, NH 03302-0095
2018-01-18 www.des.nh.gov Page 1 of 3
NHDES-S-00-001
Professional Contacts Listing Form
Oil Remediation and Compliance Bureau
Voluntary Form
Licensed/Certified Employee Information:
List at least one licensed/certified employee as required to provide the company services you identify on the Company Services section of this form.Professional Engineer: / Name: ______
Email Address: ______
PE # Expiration Date:
Professional Geologist: / Name: ______
Email Address: ______
PG # Expiration Date:
Certified Asbestos Disposal Site Worker: / Name: ______
Email Address: ______
ADS Worker # Expiration Date:
API 653 Certified Employee: / Name: ______
Email Address: ______
API 653 Cert. # Expiration Date:
ICC AST Certified Employee: / Name: ______
Email Address: ______
ICC AST Cert. # Expiration Date:
ICC UST Certified Employee: / Name: ______
Email Address: ______
ICC UST Cert. # Expiration Date:
ICC UST Cert. Type(s):
NACE Certified Employee: / Name: ______
Email Address: ______
NACE Cert. # Expiration Date:
STI Certified Employee: / Name: ______
Email Address: ______
STI Cert. # Expiration Date:
Use next page for any additional employee(s).
Telephone: (603) 271-3899 Fax: (603) 271-2181 TDD Access: Relay NH 1 (800) 735-2964
PO Box 95, Concord, NH 03302-0095
2018-01-18 www.des.nh.gov Page 1 of 3
NHDES-S-00-001
Professional Contacts Listing Form
Oil Remediation and Compliance Bureau
Voluntary Form
Additional Employee Contacts:
List other employees you want included in the NHDES contacts database, including their email address.Employee: / Name: ______
Lic/Cert Type:______; #______; Expiration Date:______
Email Address:
Employee: / Name: ______
Lic/Cert Type:______; #______; Expiration Date:______
Email Address:
Employee: / Name: ______
Lic/Cert Type:______; #______; Expiration Date:______
Email Address:
Employee: / Name: ______
Lic/Cert Type:______; #______; Expiration Date:______
Email Address:
Employee: / Name: ______
Lic/Cert Type:______; #______; Expiration Date:______
Email Address:
Employee: / Name: ______
Lic/Cert Type:______; #______; Expiration Date:______
Email Address:
Employee: / Name: ______
Lic/Cert Type:______; #______; Expiration Date:______
Email Address:
Employee: / Name: ______
Lic/Cert Type:______; #______; Expiration Date:______
Email Address:
Employee: / Name: ______
Lic/Cert Type:______; #______; Expiration Date:______
Email Address:
Telephone: (603) 271-3899 Fax: (603) 271-2181 TDD Access: Relay NH 1 (800) 735-2964
PO Box 95, Concord, NH 03302-0095
2018-01-18 www.des.nh.gov Page 1 of 3