Form MO780-1089 "Application: Examination for Drinking Water Treatment, Water Distribution, Wastewater Treatment or Concentrated Animal Feeding Operations (Cafo) Waste Management Systems Operator Certificate" - Missouri

What Is Form MO780-1089?

This is a legal form that was released by the Missouri Department of Natural Resources - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2019;
  • The latest edition provided by the Missouri Department of Natural Resources;
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  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MO780-1089 by clicking the link below or browse more documents and templates provided by the Missouri Department of Natural Resources.

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Download Form MO780-1089 "Application: Examination for Drinking Water Treatment, Water Distribution, Wastewater Treatment or Concentrated Animal Feeding Operations (Cafo) Waste Management Systems Operator Certificate" - Missouri

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MISSOURI DEPARTMENT OF NATURAL RESOURCES
APPLICATION: EXAMINATION FOR DRINKING WATER TREATMENT, WATER DISTRIBUTION,
WASTEWATER TREATMENT OR CONCENTRATED ANIMAL FEEDING OPERATIONS (CAFO)
WASTE MANAGEMENT SYSTEMS OPERATOR CERTIFICATE
INSTRUCTIONS TO APPLICANT
1.
This completed original application must be postmarked at least 30 days prior to the date of the exam to the following address:
Department of Natural Resources, Accounting Program, P.O. Box 176, Jefferson City, MO 65102-0176.
2.
Please print in ink or type. You will be credited only with drinking water treatment, distribution, wastewater and CAFO related
education and experience shown in this application. If more space is needed, attach additional sheets. Be sure to list all water,
wastewater and CAFO experience regardless of which certificate examination you are applying for.
3.
Complete a separate application for each examination that you are applying for.
4.
A $45 fee is required for an initial examination or a $20 fee for a reexamination of the same type and level of certificate. Make
check or money order payable to: Department of Natural Resources. Do not send cash. Fees are nonrefundable.
5.
The applicant must sign and date the original application. Incomplete applications will be returned. Faxes and e-mails will
NOT be accepted.
6.
Make a copy of this application for your records.
GENERAL – PRINT IN INK OR TYPE
FIRST NAME
MIDDLE INITIAL
LAST NAME
SUFFIX
MR.
MS
.
HOME ADDRESS (STREET OR P.O. BOX NO.)
CITY
STATE
ZIP CODE
SOCIAL SECURITY NUMBER (REQUIRED)*
COUNTY OF RESIDENCE
EMAIL ADDRESS
DAYTIME TELEPHONE NUMBER WITH AREA CODE
HOME TELEPHONE NUMBER WITH AREA CODE
OPERATOR CERTIFICATE NUMBER (IF APPLICABLE)
*Applicants are required by state and federal law (Section 454.403,RSMo, of the Child Support Enforcement Law and Section 317 of the federal Personal Responsibility and Work
Opportunity Reconciliation Act of 1996, Public Law No. 104-193) to include your Social Security Number on this application. This allows the department to distinguish between
persons who have the same or similar names. The department will not disclose any Social Security Numbers, consistent with Section 610.035. The department cannot allow
applicants to take the exam or become certified without a valid Social Security Number.
HAVE YOU EVER HAD A CERTIFICATE SUSPENDED OR REVOKED IN ANY STATE?
NO
YES Which State(s)
EXAMINATION TYPE AND LEVEL
Select Examination Type And Level – Check Only One
Drinking Water Treatment (DW)
D
C
B
A
Drinking Water Distribution (DS)
I
II
III
Wastewater Treatment (WW)
D
C
B
A
CAFO Waste Management Systems
B
A
I certify that I am at least 18 years of age.
EXAMINATION FEE
This is my initial application to take an examination of this type and level and I am submitting $45.
I have previously taken this exam type and level but did not pass. I wish to retake the exam and I am submitting $20.
EXAMINATION LOCATION – REGULARLY SCHEDULED SESSIONS AND LOCATIONS
Regularly scheduled examinations are generally given the first Tuesday of the month, except holidays. Please check only one
box for the month and location you wish to examine in. Check the "Special Exam Session" box below and fill in the date and
location blanks if the exam is not a regularly scheduled one.
SPRINGFIELD
MACON
ST. LOUIS
POPLAR BLUFF
KANSAS CITY
JEFFERSON CITY
(KIRKWOOD)
(LEE’S SUMMIT)
JAN
JUL
FEB
AUG
JAN
FEB
MAR
JAN
FEB
MAR
SEP
APR
MAY
JUN
APR
MAY
APR
OCT
JUL
AUG
SEP
JUL
AUG
MAY
NOV
OCT
NOV
DEC
OCT
NOV
JUN
DEC
SPECIAL EXAM SESSION – FOR MULTI-DAY COURSE ATTENDEES ONLY
SPECIAL EXAM SESSION - DO NOT COMPLETE IF YOU HAVE MARKED A REGULAR SESSION ABOVE
DATE:
LOCATION:
Do you have an ADA Title I disability/impairment for which you may need assistance during the exam?
Yes
No
If yes, please enclose documentation that describes the specific accommodations requested.
MO 780-1089 (02-19)
Page 1 of 4
MISSOURI DEPARTMENT OF NATURAL RESOURCES
APPLICATION: EXAMINATION FOR DRINKING WATER TREATMENT, WATER DISTRIBUTION,
WASTEWATER TREATMENT OR CONCENTRATED ANIMAL FEEDING OPERATIONS (CAFO)
WASTE MANAGEMENT SYSTEMS OPERATOR CERTIFICATE
INSTRUCTIONS TO APPLICANT
1.
This completed original application must be postmarked at least 30 days prior to the date of the exam to the following address:
Department of Natural Resources, Accounting Program, P.O. Box 176, Jefferson City, MO 65102-0176.
2.
Please print in ink or type. You will be credited only with drinking water treatment, distribution, wastewater and CAFO related
education and experience shown in this application. If more space is needed, attach additional sheets. Be sure to list all water,
wastewater and CAFO experience regardless of which certificate examination you are applying for.
3.
Complete a separate application for each examination that you are applying for.
4.
A $45 fee is required for an initial examination or a $20 fee for a reexamination of the same type and level of certificate. Make
check or money order payable to: Department of Natural Resources. Do not send cash. Fees are nonrefundable.
5.
The applicant must sign and date the original application. Incomplete applications will be returned. Faxes and e-mails will
NOT be accepted.
6.
Make a copy of this application for your records.
GENERAL – PRINT IN INK OR TYPE
FIRST NAME
MIDDLE INITIAL
LAST NAME
SUFFIX
MR.
MS
.
HOME ADDRESS (STREET OR P.O. BOX NO.)
CITY
STATE
ZIP CODE
SOCIAL SECURITY NUMBER (REQUIRED)*
COUNTY OF RESIDENCE
EMAIL ADDRESS
DAYTIME TELEPHONE NUMBER WITH AREA CODE
HOME TELEPHONE NUMBER WITH AREA CODE
OPERATOR CERTIFICATE NUMBER (IF APPLICABLE)
*Applicants are required by state and federal law (Section 454.403,RSMo, of the Child Support Enforcement Law and Section 317 of the federal Personal Responsibility and Work
Opportunity Reconciliation Act of 1996, Public Law No. 104-193) to include your Social Security Number on this application. This allows the department to distinguish between
persons who have the same or similar names. The department will not disclose any Social Security Numbers, consistent with Section 610.035. The department cannot allow
applicants to take the exam or become certified without a valid Social Security Number.
HAVE YOU EVER HAD A CERTIFICATE SUSPENDED OR REVOKED IN ANY STATE?
NO
YES Which State(s)
EXAMINATION TYPE AND LEVEL
Select Examination Type And Level – Check Only One
Drinking Water Treatment (DW)
D
C
B
A
Drinking Water Distribution (DS)
I
II
III
Wastewater Treatment (WW)
D
C
B
A
CAFO Waste Management Systems
B
A
I certify that I am at least 18 years of age.
EXAMINATION FEE
This is my initial application to take an examination of this type and level and I am submitting $45.
I have previously taken this exam type and level but did not pass. I wish to retake the exam and I am submitting $20.
EXAMINATION LOCATION – REGULARLY SCHEDULED SESSIONS AND LOCATIONS
Regularly scheduled examinations are generally given the first Tuesday of the month, except holidays. Please check only one
box for the month and location you wish to examine in. Check the "Special Exam Session" box below and fill in the date and
location blanks if the exam is not a regularly scheduled one.
SPRINGFIELD
MACON
ST. LOUIS
POPLAR BLUFF
KANSAS CITY
JEFFERSON CITY
(KIRKWOOD)
(LEE’S SUMMIT)
JAN
JUL
FEB
AUG
JAN
FEB
MAR
JAN
FEB
MAR
SEP
APR
MAY
JUN
APR
MAY
APR
OCT
JUL
AUG
SEP
JUL
AUG
MAY
NOV
OCT
NOV
DEC
OCT
NOV
JUN
DEC
SPECIAL EXAM SESSION – FOR MULTI-DAY COURSE ATTENDEES ONLY
SPECIAL EXAM SESSION - DO NOT COMPLETE IF YOU HAVE MARKED A REGULAR SESSION ABOVE
DATE:
LOCATION:
Do you have an ADA Title I disability/impairment for which you may need assistance during the exam?
Yes
No
If yes, please enclose documentation that describes the specific accommodations requested.
MO 780-1089 (02-19)
Page 1 of 4
EDUCATION
None
High School Diploma
GED – Year Obtained _____
___
HIGH SCHOOL NAME
YEAR GRADUATED
CITY, STATE
MULTI-DAY WATER TREATMENT, WATER DISTRIBUTION, WASTEWATER AND CAFO COURSES AND HOME STUDY COURSES
COURSE TITLE
LOCATION
STARTING DATE
ENDING DATE
MO. COURSE APPROVAL NO.
HOURS
OTHER TRAINING (TRADE OR VOCATIONAL SCHOOL, MILITARY, ETC.)
SCHOOL NAME
LOCATION
STARTING DATE
ENDING DATE
SUBJECTS
HOURS
COLLEGE/UNIVERSITY (INCLUDE A COPY OF YOUR TRANSCRIPT)
Check here if transcript previously submitted
DATE
SCHOOL NAME
LOCATION
DEGREE TYPE
MAJOR
RECEIVED
METHOD OF PAYMENT
CHECK OR MONEY ORDER ENCLOSED (NO CASH)
COMPLETED VOUCHER FORM (DW VOUCHERS VALID ONLY FOR DW OR DS EXAMS - WW VOUCHERS VALID ONLY FOR WW EXAMS)
CREDIT CARD OR eCHECK – Choose one of the following links to pay online.
Confirm the link description matches the type of exam selected on page 1.
Failure to provide confirmation number will result in an incomplete application which will be returned. This may
require a new exam date to be selected.
DW or DS exam –
https://magic.collectorsolutions.com/magic-ui/payments/mo-natural-resources/260/
Confirmation Number_________________________________________________
WW or CAFO exam –
https://magic.collectorsolutions.com/magic-ui/payments/mo-natural-resources/261/
Confirmation Number___________________________________________________
PAYMENT CONTACT NAME
DAYTIME PHONE NUMBER
ORGANIZATION NAME
(IF DIFFERENT FROM APPLICANT)
NOTE: Effective July 1, 2014, per Chapter 37, Section 37.007, of the Missouri Revised Statutes, electronic payments will include a transaction fee. The
transaction fee is being paid to a third party vendor, not to the Missouri Department of Natural Resources.
SIGNATURE IS REQUIRED ON PAGE 4 OF THE APPLICATION.
INCOMPLETE APPLICATIONS WILL BE RETURNED.
DEPARTMENT OF NATURAL RESOURCES OFFICE USE ONLY (PLEASE DO NOT WRITE BELOW THIS LINE)
AMOUNT RECEIVED
CHECK/VOUCHER NUMBER
RECEIVED BY
DATE RECEIVED
CERTIFICATE LEVEL ISSUED
CERTIFICATION NUMBER
DATE ISSUED
RENEWAL DATE
ISSUED BY
POSTMARK DATE
MO 780-1089 (02-19)
Page 2 of 4
EMPLOYMENT HISTORY
MAKE COPIES AS NEEDED
Be sure to list all water, wastewater and CAFO experience regardless of which certificate examination you are applying for. Begin
with your present employment and work backwards listing your experience. Complete a separate employment history section for each job.
Each time you changed employers or each time your duties significantly changed, complete a new employment history section. If
you held more than one position with the same employer with different duties or different levels of responsibility, list the positions separately
as though they were for separate employers. If you need additional pages, make copies and attach them to the application. Indicate the
number of employment history sheets you are attaching to the application in the signature block. Links to the Operator Certification
Regulations can be found at www.dnr.mo.gov/env/wpp/opcert/oprtrain.htm. Example work duties are provided in the regulations.
I do NOT have any relevant employment history applicable to drinking water distribution, drinking water treatment, wastewater treatment,
wastewater collections, or concentrated animal feeding operations.
APPLICANT NAME
LAST 4 OF SSN
EMPLOYMENT HISTORY
EMPLOYER’S NAME
%
AREAS OF RESPONSIBILITY
MO NPDES # AND/OR
MO PWSID #
DISTRIBUTION SYSTEM OPERATIONS (10 CSR 60-14)
EMPLOYER’S ADDRESS
DRINKING WATER TREATMENT OPERATIONS (10 CSR 60-14)
CITY, STATE, ZIP CODE
WASTEWATER TREATMENT OPERATIONS (10 CSR 20-9)
START DATE: MO/DAY/YEAR
END DATE: MO/DAY/YEAR
COLLECTION SYSTEM OPERATIONS
(EQUIVALENT WW/DS EXPERIENCE ONLY-NO IN-PLANT ACTUAL
OPERATIONAL EXPERIENCE GIVEN) (10 CSR 60-14) (10 CSR 20-9)
AVG HOURS PER WEEK
JOB POSITION/TITLE
CONCENTRATED ANIMAL FEEDING WASTE MANAGEMENT SYSTEMS
OPERATIONS (10 CSR 20-14)
WORK TELEPHONE WITH AREA CODE
OTHER
(DESCRIBE:______________________________________________________)
SUPERVISOR’S NAME, TITLE,TELEPHONE WITH AREA CODE
TOTAL (CANNOT EXCEED 100%)
EMPLOYMENT HISTORY
EMPLOYER’S NAME
%
AREAS OF RESPONSIBILITY
MO NPDES # AND/OR
MO PWSID #
DISTRIBUTION SYSTEM OPERATIONS (10 CSR 60-14)
EMPLOYER’S ADDRESS
DRINKING WATER TREATMENT OPERATIONS (10 CSR 60-14)
CITY, STATE, ZIP CODE
WASTEWATER TREATMENT OPERATIONS (10 CSR 20-9)
START DATE: MO/DAY/YEAR
END DATE: MO/DAY/YEAR
COLLECTION SYSTEM OPERATIONS
(EQUIVALENT WW/DS EXPERIENCE ONLY-NO IN-PLANT ACTUAL
OPERATIONAL EXPERIENCE GIVEN) (10 CSR 60-14) (10 CSR 20-9)
AVG HOURS PER WEEK
JOB POSITION/TITLE
CONCENTRATED ANIMAL FEEDING WASTE MANAGEMENT SYSTEMS
OPERATIONS (10 CSR 20-14)
WORK TELEPHONE WITH AREA CODE
OTHER
(DESCRIBE:______________________________________________________)
SUPERVISOR’S NAME, TITLE,TELEPHONE WITH AREA CODE
TOTAL (CANNOT EXCEED 100%)
EMPLOYMENT HISTORY
EMPLOYER’S NAME
%
AREAS OF RESPONSIBILITY
MO NPDES # AND/OR
MO PWSID #
DISTRIBUTION SYSTEM OPERATIONS (10 CSR 60-14)
EMPLOYER’S ADDRESS
DRINKING WATER TREATMENT OPERATIONS (10 CSR 60-14)
CITY, STATE, ZIP CODE
WASTEWATER TREATMENT OPERATIONS (10 CSR 20-9)
START DATE: MO/DAY/YEAR
END DATE: MO/DAY/YEAR
COLLECTION SYSTEM OPERATIONS
(EQUIVALENT WW/DS EXPERIENCE ONLY-NO IN-PLANT ACTUAL
OPERATIONAL EXPERIENCE GIVEN) (10 CSR 60-14) (10 CSR 20-9)
AVG HOURS PER WEEK
JOB POSITION/TITLE
CONCENTRATED ANIMAL FEEDING WASTE MANAGEMENT SYSTEMS
OPERATIONS (10 CSR 20-14)
WORK TELEPHONE WITH AREA CODE
OTHER
(DESCRIBE:______________________________________________________)
SUPERVISOR’S NAME, TITLE,TELEPHONE WITH AREA CODE
TOTAL (CANNOT EXCEED 100%)
MO 780-1089 (02-19)
Page 3 of 4
EMPLOYMENT HISTORY
EMPLOYMENT HISTORY
EMPLOYER’S NAME
%
AREAS OF RESPONSIBILITY
MO NPDES # AND/OR
MO PWSID #
DISTRIBUTION SYSTEM OPERATIONS (10 CSR 60-14)
EMPLOYER’S ADDRESS
DRINKING WATER TREATMENT OPERATIONS (10 CSR 60-14)
CITY, STATE, ZIP CODE
WASTEWATER TREATMENT OPERATIONS (10 CSR 20-9)
START DATE: MO/DAY/YEAR
END DATE: MO/DAY/YEAR
COLLECTION SYSTEM OPERATIONS
(EQUIVALENT WW/DS EXPERIENCE ONLY-NO IN-PLANT ACTUAL OPERATIONAL
EXPERIENCE GIVEN) (10 CSR 60-14) (10 CSR 20-9)
AVG HOURS PER WEEK
JOB POSITION/TITLE
CONCENTRATED ANIMAL FEEDING WASTE MANAGEMENT SYSTEMS
OPERATIONS (10 CSR 20-14)
WORK TELEPHONE WITH AREA CODE
OTHER
(DESCRIBE:______________________________________________________)
SUPERVISOR’S NAME, TITLE,TELEPHONE WITH AREA CODE
TOTAL (CANNOT EXCEED 100%)
EMPLOYMENT HISTORY
EMPLOYER’S NAME
%
AREAS OF RESPONSIBILITY
MO NPDES # AND/OR
MO PWSID #
DISTRIBUTION SYSTEM OPERATIONS (10 CSR 60-14)
EMPLOYER’S ADDRESS
DRINKING WATER TREATMENT OPERATIONS (10 CSR 60-14)
CITY, STATE, ZIP CODE
WASTEWATER TREATMENT OPERATIONS (10 CSR 20-9)
START DATE: MO/DAY/YEAR
END DATE: MO/DAY/YEAR
COLLECTION SYSTEM OPERATIONS
(EQUIVALENT WW/DS EXPERIENCE ONLY-NO IN-PLANT ACTUAL OPERATIONAL
EXPERIENCE GIVEN) (10 CSR 60-14) (10 CSR 20-9)
AVG HOURS PER WEEK
JOB POSITION/TITLE
CONCENTRATED ANIMAL FEEDING WASTE MANAGEMENT SYSTEMS
OPERATIONS (10 CSR 20-14)
WORK TELEPHONE WITH AREA CODE
OTHER
(DESCRIBE:______________________________________________________)
SUPERVISOR’S NAME, TITLE,TELEPHONE WITH AREA CODE
TOTAL (CANNOT EXCEED 100%)
APPLICANT SIGNATURE (REQUIRED)
I hereby certify that this application and all attachments contain no willful misrepresentation or falsifications and that the information given by
me is true and complete to the best of my knowledge and belief. I am aware that should investigation at any time disclose any such
misrepresentation or falsification of fact, this application will be rejected and my Missouri certification revoked. I also understand that
previous applications will be checked for inconsistencies. I am attaching
employment history sheets to this application.
FIRST NAME / LAST NAME (PRINT)
LAST 4 OF SSN
SIGNATURE OF APPLICANT
DATE
APPLICATION CHECKLIST:
SIGN AND DATE APPLICATION (PAGE 4)
COMPLETE EMPLOYMENT HISTORY
SECTION INCLUDE PAYMENT
INCOMPLETE APPLICATIONS WILL BE RETURNED
NOTE: TO ENSURE THIS APPLICATION IS MAILED ON TIME, IT IS RECOMMENDED THAT YOU MAIL IT YOURSELF. ADMISSION
LETTERS ARE MAILED TO EXAMINEES TWO WEEKS PRIOR TO THE EXAM DATE TO THE ADDRESS PROVIDED ON THIS
APPLICATION.
MO 780-1089 (02-19)
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