Chp516_0419.pdf Destroy Previous Editions STATE OF CALIFORNIA DEPARTMENT OF CALIFORNIA HIGHWAY PATROL APPLICATION - HAZARDOUS AGRICULTURAL MATERIALS CERTIFICATE CHP 516 (New 1-18) OPI 062 Page 1 of 1 Section 12804.2 of the California Vehicle Code (CVC), requires a person requesting a DL 267, Hazardous Agricultural Materials Transportation Verification of Training (HAM Certificate), to submit a completed application and a copy of a record of current training meeting the requirements below, to the California Highway Patrol (CHP). Pursuant to Section 12515(b) CVC, the applicant must be at least 21 years of age. Additional information is available at: www.chp.ca.gov. INSTRUCTIONS: n Complete the applicant information in SECTION A. n Review the record of current training document requirements in SECTION B. n Sign and date the application in SECTION C. n Submit the documents as required in SECTION D. SECTION A APPLICANT INFORMATION NAME (FIRST, MIDDLE, LAST) DATE OF BIRTH (MM/DD/YYY) CALIFORNIA DRIVER LICENSE NUMBER ADDRESS (NUMBER AND STREET) CITY STATE ZIP CODE MAILING ADDRESS (NUMBER AND STREET), IF DIFFERENT THAN ABOVE CITY STATE ZIP CODE PHONE NUMBER EMAIL ADDRESS SECTION B RECORD OF CURRENT TRAINING (Title 49, Code of Federal Regulations, Section 172.704[d]) The enclosed record of current training (e.g., certificate of completion) must indicate all of the following: n Name of applicant. n A training completion date within the last three years. n Description or location of the training materials used to fulfill the training requirements. n Name and address of the person who provided the training. n A certification statement that the applicant has been trained and tested. SECTION C APPLICANT CERTIFICATION I certify under penalty of perjury under the laws of the State of California that the foregoing are true and correct and I have successfully completed the training indicated by the enclosed record of current training. APPLICANT SIGNATURE DATE SECTION D SUBMISSION To obtain a HAM Certificate from the CHP, please mail the following items to the address shown at right. n This original completed application. n A copy of a record of current training meeting the requirements of SECTION B above. DO NOT SUMBIT PAYMENT WITH THIS APPLICATION. Mail documents to: California Highway Patrol Attention: 062 HAM Cert P.O. Box 942898 Sacramento, CA 94298-0001 DO NOT WRITE IN THIS AREA - CHP USE ONLY VERIFIED BY (NAME AND ID NUMBER) DATE CONTROL NUMBER

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Page 1: APPLICATION - HAZARDOUS AGRICULTURAL MATERIALS … › CommercialVehicleSectionSite › Documents › Chp516.pdfAPPLICATION - HAZARDOUS AGRICULTURAL MATERIALS CERTIFICATE . CHP 516

Chp516_0419.pdfDestroy Previous Editions

STATE OF CALIFORNIA DEPARTMENT OF CALIFORNIA HIGHWAY PATROL

APPLICATION - HAZARDOUS AGRICULTURAL MATERIALS CERTIFICATE CHP 516 (New 1-18) OPI 062

Page 1 of 1

Section 12804.2 of the California Vehicle Code (CVC), requires a person requesting a DL 267, Hazardous Agricultural Materials Transportation Verification of Training (HAM Certificate), to submit a completed application and a copy of a record of current training meeting the requirements below, to the California Highway Patrol (CHP). Pursuant to Section 12515(b) CVC, the applicant must be at least 21 years of age. Additional information is available at: www.chp.ca.gov.

INSTRUCTIONS: n Complete the applicant information in SECTION A. n Review the record of current training document requirements in SECTION B. n Sign and date the application in SECTION C. n Submit the documents as required in SECTION D.

SECTION A APPLICANT INFORMATIONNAME (FIRST, MIDDLE, LAST) DATE OF BIRTH (MM/DD/YYY) CALIFORNIA DRIVER LICENSE NUMBER

ADDRESS (NUMBER AND STREET) CITY STATE ZIP CODE

MAILING ADDRESS (NUMBER AND STREET), IF DIFFERENT THAN ABOVE CITY STATE ZIP CODE

PHONE NUMBER EMAIL ADDRESS

SECTION B RECORD OF CURRENT TRAINING (Title 49, Code of Federal Regulations, Section 172.704[d]) The enclosed record of current training (e.g., certificate of completion) must indicate all of the following:

n Name of applicant. n A training completion date within the last three years. n Description or location of the training materials used to fulfill the training requirements. n Name and address of the person who provided the training. n A certification statement that the applicant has been trained and tested.

SECTION C APPLICANT CERTIFICATIONI certify under penalty of perjury under the laws of the State of California that the foregoing are true and correct and I have successfully completed the training indicated by the enclosed record of current training. APPLICANT SIGNATURE DATE

SECTION D SUBMISSIONTo obtain a HAM Certificate from the CHP, please mail the following items to the address shown at right.

n This original completed application. n A copy of a record of current training meeting the requirements of SECTION B above.

DO NOT SUMBIT PAYMENT WITH THIS APPLICATION.

Mail documents to:

California Highway Patrol Attention: 062 HAM Cert P.O. Box 942898 Sacramento, CA 94298-0001

DO NOT WRITE IN THIS AREA - CHP USE ONLYVERIFIED BY (NAME AND ID NUMBER) DATE CONTROL NUMBER