"Operator Verification Form" - Connecticut

Operator Verification Form is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

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Download "Operator Verification Form" - Connecticut

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OPERATOR VERIFICATION FORM
General Information:
Each Community or Non-Transient Non-Community Public Water System (PWS) regulated treatment plant, distribution
system and small water system is required to have a certified operator. A certified operator is an individual who has
been certified by the Drinking Water Section (DWS) and has met the education, experience and examination
requirements specified in section 25-32-7a to 25-32-14 of the Regulations of Connecticut State Agencies.
The PWS must designate a “chief operator” for each of its water treatment plants, distribution systems and small water
systems. A chief operator is a certified operator who has direct responsible charge (active daily responsibility) for the
operation and maintenance of a treatment plant, distribution system, or small water system.
You may obtain Contractor List of Certified Operators from the internet go to
https://www.elicense.ct.gov/
(Click on
“ONLINE SERVICES” then “Generate Roster(s)” then “Drinking Water System Operators”)
PWSs should use this form to notify the DWS of any certified operator changes for its system. A representative of the
PWS and the certified operator of record must sign this form.
PWS OWNER OR LEGAL CONTACT PERSON ATTESTATION:
I verify that the below listed modification (i.e. addition and/or removal) of Certified Water Operator's responsibility for
the named PWS is correct.
PWS Name: _______________________________ PWSID: _________________ Town:___________________
*1
(Signature)
Title
Signature Date
(print name)
(phone #)
CERTIFIED OPERATOR ATTESTATION:
Certified Operator’s Signature
I verify that the listed modification to the
Chief
my operational responsibility / assignment
Certification
Operator
Add (A),
Effective
of the above listed PWS is correct. *2
Certified Operator Name
Number
(Y, N)
Remove (R)
Date
NOTE: If an operator is being designated as the Chief Operator of a PWS then the signature of the Owner or
Administrative Contact and the operator is required.
*1 If the Certified Operator is deleting his or her assignment then the signature of the PWS Owner and/or Legal
Contact Person is not required.
*2 If the PWS Owner and/or Legal Contact Person is deleting an operator assignment then the signature of the
operator is not required.
Phone: (860) 509-7333 • Fax: (860) 509-7359 • VP: (860) 899-1611
410 Capitol Avenue, MS#51WAT, P.O. Box 340308
Hartford, Connecticut 06134-0308
www.ct.gov/dph
Affirmative Action/Equal Opportunity Employer
OPERATOR VERIFICATION FORM
General Information:
Each Community or Non-Transient Non-Community Public Water System (PWS) regulated treatment plant, distribution
system and small water system is required to have a certified operator. A certified operator is an individual who has
been certified by the Drinking Water Section (DWS) and has met the education, experience and examination
requirements specified in section 25-32-7a to 25-32-14 of the Regulations of Connecticut State Agencies.
The PWS must designate a “chief operator” for each of its water treatment plants, distribution systems and small water
systems. A chief operator is a certified operator who has direct responsible charge (active daily responsibility) for the
operation and maintenance of a treatment plant, distribution system, or small water system.
You may obtain Contractor List of Certified Operators from the internet go to
https://www.elicense.ct.gov/
(Click on
“ONLINE SERVICES” then “Generate Roster(s)” then “Drinking Water System Operators”)
PWSs should use this form to notify the DWS of any certified operator changes for its system. A representative of the
PWS and the certified operator of record must sign this form.
PWS OWNER OR LEGAL CONTACT PERSON ATTESTATION:
I verify that the below listed modification (i.e. addition and/or removal) of Certified Water Operator's responsibility for
the named PWS is correct.
PWS Name: _______________________________ PWSID: _________________ Town:___________________
*1
(Signature)
Title
Signature Date
(print name)
(phone #)
CERTIFIED OPERATOR ATTESTATION:
Certified Operator’s Signature
I verify that the listed modification to the
Chief
my operational responsibility / assignment
Certification
Operator
Add (A),
Effective
of the above listed PWS is correct. *2
Certified Operator Name
Number
(Y, N)
Remove (R)
Date
NOTE: If an operator is being designated as the Chief Operator of a PWS then the signature of the Owner or
Administrative Contact and the operator is required.
*1 If the Certified Operator is deleting his or her assignment then the signature of the PWS Owner and/or Legal
Contact Person is not required.
*2 If the PWS Owner and/or Legal Contact Person is deleting an operator assignment then the signature of the
operator is not required.
Phone: (860) 509-7333 • Fax: (860) 509-7359 • VP: (860) 899-1611
410 Capitol Avenue, MS#51WAT, P.O. Box 340308
Hartford, Connecticut 06134-0308
www.ct.gov/dph
Affirmative Action/Equal Opportunity Employer