Evaluation Application for Power Engineer, Operator and Safety Awareness Examinations Form 1206

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Please refer to our website or contact a Regional Office to locate the BC Safety Authority office nearest you. Coquitlam Kelowna Nanaimo Victoria 604-927-2041 250-861-7313 250-716-5200 250-952-4444 fax 604-927-2047 fax 250-861-7349 fax 250-716-5212 fax 250-952-4458 fax 778-396-2174 Kamloops Langley Prince George 250-314-6000 604-539-3573 250-614-9972 fax 250-377-4406 fax 604-539-3570 fax 250 614 9949
New Westminster
505 - 6th Street, Suite 200, New Westminster, BC, V3L 0E1
Website: www.safetyauthority.ca fax 1-888-660-3508
Local Phone: 778-396-2000
Toll Free: 1-866-566-SAFE (7233)
EVALUATION APPLICATION FOR POWER ENGINEER, OPERATOR & SAFETY AWARENESS EXAMINATIONS
The information on this form is collected to administer the provisions of the Safety Standards Act. If you have questions about the collection, use or disclosure of this information, contact the Records, Information & Privacy Analyst at the BC Safety Authority. Applicants must read the Regulation for the required work experience. Examination questions and answer keys are kept confidential and are the property of the BC Safety Authority.
A. Applicant:
Last Name: Suite No: P.O. Box: Primary Phone:
(Please print clearly) Given Name(s): Street Name: Station: Cell: Reg. No: E-mail: Preferred Method of Contact: Middle Initial: City: Date of Birth: Province:
YY
Legal Name Street No: Rural Route:
/
MM
/
DD
Postal Code:
B.C. Certification Held: ________ Class

E-mail

Mail
Mandatory Evaluation: (Required for the following examinations)
□ 1B4 □ 2B3
Training Provider
□ 3B2 □ 4B1
□ 5B1 (Boiler/Refrigeration) □ IFO
Course
□ Safety Awareness (Boiler/Refrigeration) □ Oilwell Boiler Operator
Duration
□ Antique Show Boiler Operator
Approved Training Courses: (Please provide only those courses that you have passed)
Year Completed
Plant Information: (Please declare additional Plant Information on Page 2 if space is insufficient)
Plant Name: Plant Address: Type of Plant (choose one) Unit No: City: Province: Plant Reg. No.
(for Safety Awareness applicants only)
Phone No:
□ HP Steam
□ LP Steam
□ LT/LP Fluid
□ HT/HP Fluid
□ LP Fluid
□ HP Thermal Fluid
□ LP Thermal Fluid
□ Refrigeration
Plant Experience:
Duration of Experience
From Day Mon Year Day To
Plant Specifications
Boiler Working Pressure Chief Engineer (Months) Plant Classification. Total Plant Capacity m2 / kW
Position Held (see definition on page 3)
Power Engineer Trainee (Months)
MM
Asst. Engineer (Months)
Shift Engineer (Months)
Mon
Year
Name of Chief Engineer: ______________________________ or Name of Company official: ______________________________
Reg. No. _________________________ Title: _________________________
Phone: ____________________ Phone: ____________________
NOTE: It is an offence under section 72 (1) (f) of the BC Safety Standards Act to knowingly provide false information on this form, All information I have given on this application is true and correct, and all work experience provided on this form has been verified by the Chief Engineer or Company Official at each plant.
YY DD
Applicant’s signature:
FRM-1206-00 (2009-04-23)
Page 1 of 3
Acceptable Experience (Months)
Asst. Chief Engineer (months)
Asst, Shift Engineer (Months)
EVALUATION APPLICATION FOR POWER ENGINEER, OPERATOR & SAFETY AWARENESS EXAMINATIONS
Additional Plant Information:
Plant Information:
Plant Name: Plant Address: Type of Plant: (choose one)
(Please declare any further plant operating experience)
Unit No: City: Province:
Plant Reg. No.
(for Safety Awareness applicants only)
Phone No:
□ HP Steam
□ LP Steam
□ LT/LP Fluid
□ HT/HP Fluid
□ LP Fluid
□ HP Thermal Fluid
□ LP Thermal Fluid □ Refrigeration
(see definition on page 3) Acceptable Experience Acceptable Experience
DD
Plant Experience:
Duration of Experience
From Day Mon Year Day To Mon
Year
Plant Specifications
Plant Classification. Total Plant Capacity m2 / kW Boiler Working Pressure Chief Engineer (Months)
Position Held
Shift Engineer (Months) Asst. Chief Engineer (months)
Asst, Shift Engineer (Months)
Name of Chief Engineer: or Name of Company official:
_____________________________ _____________________________
Reg. No.__________________________ Title:__________________________
Phone: ____________________ Phone: ____________________
Plant Information:
Plant Name: Plant Address: Type of Plant (choose one) Unit Numbers: City: Province: Plant Reg. No.
(for Safety Awareness applicants only)
Phone No:
□ HP Steam
□ LP Steam
□ LT/LP Fluid
□ HT/HP Fluid
□ LP Fluid
□ HP Thermal Fluid □ LP Thermal Fluid
Position Held
Shift Engineer (Months) Asst. Chief Engineer (months)
Asst. Engineer (Months) Asst. Engineer (Months)
YY
□ Refrigeration
Plant Experience:
Duration of Experience
From Day Mon Year Day To Mon
Year
Plant Specifications
Plant Classification. Total Plant Capacity m2 / kW Boiler Working Pressure Chief Engineer (Months)
(see definition on page 3) Power Engineer Trainee
Date:
MM
Name of Chief Engineer: or Name of Company official:
_____________________________ _____________________________
Reg. No.__________________________ Title:__________________________
B. Safety Officer / Chief Examiner Use:
Reviewed by: Safety Officer / Chief Examiner Reviewed Application Safety Officer No.: Based on Regulation – section/s: Comments:
□ Accepted
Tran Code: E112 GST: $ 87391 2802 RT
□ Rejected
C. Office Use Only:
Office: Fee: $ Technology: BP Total Fee: $ File No: Payment Method: Tran Date:
NSF Cheques are subject to a charge. Please refer to our fee schedule for more information.
NOTE: You may download a copy of the above Plant Information form via the BC Safety Authority website at www.safetyauthority.ca. It is recommended you print another copy of this page for submission if additional experience needs to be submitted. FRM-1206-00 (2009-04-23) Page 2 of 3
Asst, Shift Engineer (Months)
Phone: ____________________ Phone: ____________________
Power Engineer Trainee
EVALUATION APPLICATION FOR POWER ENGINEER, OPERATOR & SAFETY AWARENESS EXAMINATIONS
Information for Applicants:
• • Your application may be subject to audit. Please ensure that you keep all documentation associated with your application.
Ensure you have reviewed and understand the following policies and information before application submission.
Evaluation Policies:
1. 2. 3. 4. 5. This evaluation application form must be filled out and submitted with any application for Power Engineer or Operator examination requiring confirmation of qualifying/firing time, and/or education. To reserve for an examination sitting, applications for examination must be received before the scheduled cut off dates prior to any requested examination sitting. Evaluation fees are non-refundable. Examination schedules and Power Engineers syllabi can be found on our website at: www.safetyauthority.ca If you are from out of province, and applying for a certificate, please submit an “Application for Power Engineering Granted Certificate.”
Power Engineer Work Experience:
1. 2. Unit ID is the number registered under the Safety Standards Act Plant is classified by the type and total capacity of the boiler or refrigeration equipment that is connected to the same header or refrigeration system, as the case may be and should be designated First Class, Second Class, Third Class, Fourth Class, Fifth Class - Boiler or Refrigeration. Where the work experience has been obtained in different plants, please provide the Duration of Experience, Plant specifications, and the Position(s) held under the Plant Experience section. Please keep a copy of your resume/testimonial detailing the type, capacity, pressure and temperature of equipment operated and the duties and responsibilities of the operator. Where completion of an approved “Power Engineer” course is being applied to reduce the required work experience, please provide the training provider, course, duration, and year of completion under the Approved Training Courses section. When experience is being claimed as qualifying time, a resume of the type of equipment operated and the duties and responsibilities of the operator must be retained. The resume must be signed by the Chief Engineer or a Company Official. Experience gained in the operation, design, construction, repair or maintenance of equipment to which the Power Engineers, Boiler, Pressure Vessel and Refrigeration Safety Regulations applies must be covered by a separate testimonial. For plant classification, see Power Engineers, Boiler, Pressure Vessel and Refrigeration Safety Regulation, Part 1, Div. III.
3.
4. 5. 6. 7.
Definitions:
“Shift Engineer” means a power engineer who is a person in charge of a plant under the supervision of a chief engineer or one who is in charge of a plant when the chief engineer is absent. “Assistant Shift Engineer” means the power engineer who is under the immediate supervision of the shift engineer and assists the shift engineer with the supervision or operation of the plant. “Assistant Engineer” means the power engineer who is a person in charge of a part of a plant under the supervision of the shift engineer. “Power Engineer Trainee” means an individual who has received training and who assists in the operation of a plant but does not hold a certificate of qualification. (12 months for 4th class & 5th class refrigeration, 8 months for 5th class boiler) “Acceptable Experience” gained in the operation, design, construction, repair or maintenance of equipment to which the Power Engineers, Boiler, Pressure Vessel and Refrigeration Safety Regulation applies shall be covered by a separate testimonial. (18 months for 4th class; 8 months for 5th class)
Boiler and Refrigeration Operator & Safety Awareness
1. 2. 3. 4. Training institute certificate(s) may be requested. Oilwell Boiler Operator applications must have proof of work experience from employer as per the requirements of the Power Engineers, Boiler, and Pressure Vessel & Refrigeration Safety Regulation. Ice facility operator applications must have proof of 30 days work experience from employer. A copy of the “Ice Facility Refrigeration Operators Log Book” could be requested. Documentation must be retained from the employer’s power engineer attesting that the “Safety Awareness Trainee” has received training and is qualified on in-plant shutdown and safety procedures specific to their employer’s plant.
FRM-1206-00 (2009-04-23)
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