DW Operator Designation REMOVAL/RESIGNATION Form

Facility Name *

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

Operator's Full Name *

Operator's Certificate # *

Effective Date *

Month

Day

Year

Contact Phone Number *

Contact Email Address

Resign ALL Designations? *

YES - Submit Form

NO - Select designation(s) you are resigning below.

Resign Designation 1

Resign Designation 2

Resign Designation 3

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