CONTACT/OPERATORINFORMATIONUPDATE
Please Return Completed Formto:
MTDEQ- WWOC
P.O. Box 200901
Helena, MT59620-0901
This formconstitutesanoticeofintent fromthewater or wastewater systemlisted below to the State of Montana,DepartmentofEnvironmentalQuality(department) for the purpose ofproviding a means to fulfill the statutory obligation under Section 37-42-302, Montana Codes Annotated (MCA).ThisMCArequiresthatall wastewater treatment plants, watertreatment plants, or water distributionsystemsbeoperatedunderthe supervisionofafullycertifiedoperatorinresponsiblechargetoensurethepropermanagement,operation,and maintenance of the system.
SYSTEM NAME: Date:
PWSID#:or MPDES#:
SystemType:Community Water SystemNon-transient Non-community Water System Public Sewage System Permitted WastewaterSystem
System Information
# of Total Service Connections: Resident Population:
# of Active Service Connections: Non-Resident Population:
Seasonal System:Y or NIf Yes, SeasonalStartDate:
SeasonalEndDate:
Type of Treatment: (give a brief description of the typeof treatment used for water and/or wastewater system):
OwnerInformation(Usemayorifincorporated;usepresident, if incorporated district, HOA, or WUA): Name: Phone #: Mailing Address: Business Email:
City,StateZipCode:
Administrative Contact (Person that all systemcorrespondenceshouldbesentto):
Name:Phone #: MailingAddress: Business Email: City, State &ZipCode: Financial Contact
Name:Phone#: MailingAddress: Business Email: City,StateZipCode:
Thecertifiedoperator shallberesponsiblefortheoperationandmanagementofthe systemto ensure that the abovelistedsystemisincompliancewith all stated regulations.To ensure the proper operation of the above system,thecertifiedoperatorinresponsiblechargeagreestoperformthetypicalduties and responsibilities as specified within the laws and rules ofthe departmentand those included onthe enclosed “Typical Duties and Responsibilities of a Certified Operator.” *In some cases, the certified operatorinresponsiblechargecan supervisetheoperationofthesystemwithoutbeingonsiteprovidedthe fully certified operator is on call when there is a certified operator-in-trainingat the systemsite.Note:BacteriologicalsamplesforaCommunityor Non-transient Non-community public water supply systems must be collected by a operator certified by the department (ARM 17.38.225(5)).*
Check all of the following boxes that are appropriate andcomplete requested information (Note that a certifiedoperatormustbedesignatedfor each of the water and wastewater classifications that apply to your system.):
Existing fully certified staffmember(s)(Note:ifanyofthebelow are contract operators then please complete the enclosed ContractOperator Designation Sheet):
Operator Name:Certification #Class & Type: Mailing Address: Business Email: City: State: Zip: Signature of Operator: ______
Operator Name: Mailing Address: City:
Certification #
Business Email:
State:
Class & Type:
Zip:
Signature of Operator: ______
Operator Name: Mailing Address: City:
Certification #
Business Email:
State:
Class & Type:
Zip:
Signature of Operator: ______
Existing staff member who holds anoperator-in-training certificate and is working towards full certification: Operator Name: Certification # Class & Type: Mailing Address: Business Email: City: State: Zip:
Signature of Operator: ______
Operator Name: Mailing Address: City:
Certification #
Business Email:
State:
Class & Type:
Zip:
Signature of Operator: ______
Existing staff member who holds an operator-in-trainingandisworkingtowardsfullcertification:Operator Name: Certification # Class & Type: Mailing Address: Business Email: City: State: Zip:
Signature of Operator: ______
Existingstaffmemberwhowillgothroughtheprocess to become fully certified, but is not properly certified(Note:ifthisindividual isgoingtobetheonlyoperatorforyoursystemour office must receive the completed enclosed Temporary Request Form):
OperatorName:Certification#Class & Type: MailingAddress: Business Email: City: State: Zip: Signature of Operator: ______
Operator Name: Mailing Address: City:
Certification #
Business Email:
State:
Class & Type:
Zip:
Signature of Operator: ______
ATTACHADDITIONALLISTOFOPERATORSIFNEEDED,PLEASEPROVIDEALLINFORMATION.
Thisagreementissubjecttothefollowingconditions:
1)Itistheresponsibilityoftheownerofthewastewatertreatmentplants,watertreatmentplants,orwater distributionsystemstoensurethattheoperator maintains a currently validMontana water and wastewatercertificationequaltoormorecomplexthantheclassofthesystemtheyareoperating.
2)The above stated systemrecognizes its obligationand assumes the responsibility of notifying the Department,inwriting,within3workingdaysof thelossofanoperatororachangeincertified operators.
3)The above stated systemand the certified operator shall notifyallinterestedparties of the existence and responsibilities ofthisagreement.
I certify thatthe information contained in this compliance plan for meeting the certified operator requirements oftheStateofMontanaisaccurate:
Signature of SystemOwner: ______
(If incorporatedcommunity, mayor must sign.Ifincorporated district, HOA, WUA the president must sign):
Signature of the Certified Operator:_ _ _ _
(Certified Operator in Responsible Charge)
______
______
______
_ _ _ _ _
_ _ _ _ _
CONTRACT OPERATOR DESIGNATIONSHEET
(Optional:Onlyrequiredifyousystem is under the direct responsible Charge of a contract fully certified operator)
complieswiththecertifiedoperator requirements by contracting with: (name of system)
Company Name (if applicable): Mailing Address: Business Email: City: State: Zip: Phone #:
List information on all contract operators who are theCertified Operators in Responsible Charge for this system:
OperatorName:Certification#Class & Type: MailingAddress: Business Email: City: State: Zip: Signature of Operator: ______
Operator Name: Mailing Address: City:
Certification #
Business Email:
State:
Class & Type:
Zip:
Signature of Operator: ______
Operator Name: Mailing Address: City:
Certification #
Business Email:
State:
Class & Type:
Zip:
Signature of Operator: ______List information on all other systems this contractor or company is responsible for:
Numberofotherpublicwatersystemsorpublicwastewatersystemspresentlyoperated:
Pleaselistallpublicwatersystemsorpublicwastewatersystembelow(Attachadditionallistifneeded):
PWS# or MPDES #:Name:City: PWS# or MPDES #: Name: City: PWS# or MPDES #: Name: City: PWS# or MPDES #: Name: City: PWS# or MPDES #: Name: City: PWS# or MPDES #: Name: City: PWS# or MPDES #: Name: City:
TEMPORARY REQUEST FORM
Please note that the system owner must complete this form
Iftheoperatorinresponsiblechargeofthesystemisnotfullycertified,thesystemownercanrequestatemporarycertification.IfapprovedbytheDepartmentofEnvironmentalQuality,thetemporarycertificationmaybevalidforuptosix monthsfromthedateofissuance(pendingtheapplicationonfileiscurrent,allfeesarepaidinfull,andthesystemandoperatorareingoodstandingwiththeDepartment).Pleasenotethatthesystemownermustcompletethisform.
SystemName:
OwnerName:
Phone#:
PWS#:
and/orMPDES#:
MailingAddress:BusinessEmail:
City,StateZipCode:
SystemType: / CommunityWaterSystem / Non-transientNon-communityWaterSystemPublicSewageSystem / PermittedWastewaterSystem
THE SECTION BELOW MUST BE FILLED OUTCOMPLETELY TO APPLY FORA TEMPORARY CERTIFICATION:
Thissystemisunabletohireafullycertifiedoperatorbecause(attachseparatesheetifneeded):
TemporarycertificationisrequestedforthefollowingstaffmemberwhohasNOTpassedtheappropriatecertificationexamination.Acompletedapplicationandappropriatefeesareenclosedorhavealreadybeenprocessedbyourdepartment.
OperatorName: Phone#: MailingAddress: BusinessEmail: City,StateZipCode: PositionTitle:
TemporarycertificationisrequestedforthefollowingstaffmemberwhoholdsanOperator-in-Trainingcertification:OperatorName: Certification # ClassType:
MailingAddress:Business Email: City: State: Zip: SignatureofOperator:______
SignatureofSystemOwner______
______
______
______
______
______
(If incorporatedcommunity, mayor must sign.Ifincorporated district, HOA, WUA the president must sign):