DW Operator Designation REMOVAL/RESIGNATION Form

Submitted by dlfaison on Tue, 10/12/2021 - 09:25

To remove designation or resign as ORC, please submit the following information:

Indicates required field

Facility Name

PWS ID # (Submit this form for each PWS ID #)

Operator's First Name

Operator's Last Name

Operator's Certificate #

Effective Date

Contact Phone Number

Resign ALL Designations?

Yes

Select designation(s) you are resigning below

Cross Connection

Distribution

Well

Surface