July 2025 to June 2026 Water System Operator Reimbursement Program
Operator Pre-Approval Form
All fields marked with * are required and must be filled.
Operator Information
Operator Name
*
Operator Mailing Address
*
Operator City
*
Operator State
*
Operator Zip Code
*
Operator Contact Phone Number
*
(555) 555-5555
Format: (000) 000-0000.
Operator Email
*
example@example.com
Additional information
Check this box if you would like to receive approval through email. Please note that you will not receive a paper copy.
Check this box if your community has fewer than 10,000 residents and your expenses are expected to exceed $2,000.
List certificates that you currently hold:
*
Water System Information
For the following water system, select whether you are the primary or backup operator:
*
Primary Operator
Backup Operator
Public Water System Identification Number (PWSID)
*
You can find your system's PWSID number here: https://dec.alaska.gov/DWW/
System Name
*
System Administrator Name
*
System Administrator's Phone Number
*
(555) 555-5555
Format: (000) 000-0000.
System Administrator's Email
*
example@example.com
I certify that the information provided in this application is true and complete to the best of my knowledge.
*
Yes
Operator's Signature
*
Date
*
/
Month
/
Day
Year
Date Picker Icon
Please verify that you are human
*
Preview PDF
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