"Designation Form Supervisory Wastewater System Operator" - Oregon

Designation Form Supervisory Wastewater System Operator is a legal document that was released by the Oregon Department of Environmental Quality - a government authority operating within Oregon.

Form Details:

  • Released on November 19, 2019;
  • The latest edition currently provided by the Oregon Department of Environmental Quality;
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Send completed form to:
DEQ Water Quality
Designation Form
Operator Certification Program
700 NE Multnomah St., Ste. 600
Portland, OR 97232-4100
Supervisory Wastewater System Operator
Telephone: 503-229-5161
A. SYSTEM NAME, LOCATION AND CONTACT
System Legal Name:
Owner/Permittee:
System Location:
City:
State:
Zip Code:
Mailing Address:
City:
State:
Zip Code:
DEQ Permit Number:
DEQ File Number:
County:
Wastewater Collection System Level:
SWWS
I
II
III
IV
N/A
Wastewater Treatment System Level:
SWWS
I
II
III
IV
N/A
The wastewater system owner will designate a supervisor for day-to-day operation of the wastewater system in accordance with
owner policies, any permit requirements, and as per requirements in OAR 340-049.
This form entirely replaces any previous submittal of the form. (No partial “updates” accepted).
If DEQ has classified both the collection and treatment system, the owner must designate a certified operator for each, even if the
same operator will be supervising both systems. The wastewater system owner must notify DEQ in writing within 30 days of
replacing or reassigning any designated system operator, as per OAR 340-049-0015(5) and (8).
B. COLLECTION SYSTEM PRINCIPAL DESIGNATED OPERATOR (System Supervisor*)
C-
Name of Operator
Certificate Number
Grade
Expiration Date
(SWWS, I-IV)
__________________________________________ ____________________________ _________________________
Operator’s Signature (required)
Title
Date
Alternate Collection System Supervisor or Shift Supervisor*
C-
Name of Operator
Certificate Number
Grade
Expiration Date
(SWWS, I-IV)
C. TREATMENT SYSTEM PRINCIPAL DESIGNATED OPERATOR (System Supervisor*)
T-
Name of Operator
Certificate Number
Grade
Expiration Date
(SWWS, I-IV)
__________________________________________ ____________________________ _________________________
Operator’s Signature (required)
Title
Date
Alternate Treatment System Supervisor or Shift Supervisor*
T-
Name of Operator
Certificate Number
Grade
Expiration Date
(SWWS, I-IV)
*As per OAR 340-049-0015(1), (2), (3) and (9), regardless of actual working title.
revised Nov. 19, 2019
Page 1 of 2
Send completed form to:
DEQ Water Quality
Designation Form
Operator Certification Program
700 NE Multnomah St., Ste. 600
Portland, OR 97232-4100
Supervisory Wastewater System Operator
Telephone: 503-229-5161
A. SYSTEM NAME, LOCATION AND CONTACT
System Legal Name:
Owner/Permittee:
System Location:
City:
State:
Zip Code:
Mailing Address:
City:
State:
Zip Code:
DEQ Permit Number:
DEQ File Number:
County:
Wastewater Collection System Level:
SWWS
I
II
III
IV
N/A
Wastewater Treatment System Level:
SWWS
I
II
III
IV
N/A
The wastewater system owner will designate a supervisor for day-to-day operation of the wastewater system in accordance with
owner policies, any permit requirements, and as per requirements in OAR 340-049.
This form entirely replaces any previous submittal of the form. (No partial “updates” accepted).
If DEQ has classified both the collection and treatment system, the owner must designate a certified operator for each, even if the
same operator will be supervising both systems. The wastewater system owner must notify DEQ in writing within 30 days of
replacing or reassigning any designated system operator, as per OAR 340-049-0015(5) and (8).
B. COLLECTION SYSTEM PRINCIPAL DESIGNATED OPERATOR (System Supervisor*)
C-
Name of Operator
Certificate Number
Grade
Expiration Date
(SWWS, I-IV)
__________________________________________ ____________________________ _________________________
Operator’s Signature (required)
Title
Date
Alternate Collection System Supervisor or Shift Supervisor*
C-
Name of Operator
Certificate Number
Grade
Expiration Date
(SWWS, I-IV)
C. TREATMENT SYSTEM PRINCIPAL DESIGNATED OPERATOR (System Supervisor*)
T-
Name of Operator
Certificate Number
Grade
Expiration Date
(SWWS, I-IV)
__________________________________________ ____________________________ _________________________
Operator’s Signature (required)
Title
Date
Alternate Treatment System Supervisor or Shift Supervisor*
T-
Name of Operator
Certificate Number
Grade
Expiration Date
(SWWS, I-IV)
*As per OAR 340-049-0015(1), (2), (3) and (9), regardless of actual working title.
revised Nov. 19, 2019
Page 1 of 2
D. DISCHARGE MONITORING REPORT SIGNATURE AUTHORITY
Please note, this form does not delegate discharge monitoring report signature authority. Delegating this type of signature
authority is instead submitted through one of the following linked forms
NPDES Duly Authorized Representative Form
or
Sample Letter for Delegation of Signatory
Authority. These two forms have their own separate mailing instructions.
E. CONTRACT FOR SYSTEM OPERATION OR SUPERVISION
Yes
No
Does the system owner contract / arrange for supervisory operator services?
If “Yes” please complete this section and attach a copy of the signed, written agreement to this form (required).
As per ORS 448.430(1), part-time supervision is only allowed if the approved design flow is less than 75,000
gallons per day.
Contract is for:
Collection System
Treatment System
Both
Name (Corporation, Business or Individual):
Contact Person:
Mailing Address:
City:
State:
Zip Code:
Phone Number:
email:
Contract Start Date:
Contract End Date:
Note: If one or more of the principal designated operators identified on page one of this form is a contracted operator, a
written agreement is required to comply with OAR 340-049-0015.
F. COMMENTS (Reference all attachments here)
G. SIGNATURE OF OWNER/REPRESENTATIVE ( All fields required)
I am the owner or owner’s authorized representative for the wastewater system identified on page one of this form. I have
reviewed the information contained on this form and within any attachments and verified the information is true,
complete and accurate to the best of my knowledge.
Note: This section cannot be signed by the same person as who is listed on page one.*
_____________________________________________________________
_________________________________
Signature
Date
Name (print):
Phone number:
Title:
Email address:
Notes:
(1) The principal designated operator (supervisor) must hold a valid certificate at a grade level equal to or greater than
the classification level of the system at the time of designation.
(2) An alternative supervisor or shift supervisor for Class II, III and IV systems may hold a certificate one grade lower
than the classification level of the system.
(3) The terms “certified”, “operator”, “shift supervisor”, “supervise” and “supervisor” are defined under
OAR 340-049-0010(2), (11), (16), (17), and (18).
* Only when the owner is also the operator may the page one and page two signatures be the same person.
revised Nov. 19, 2019
Page 2 of 2
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