July 2025 to June 2026 Water System Operator Reimbursement Program
System Owner Pre-Approval Form
All fields marked with * are required and must be filled.
System Owner Information
Public Water System ID Number (PWSID)
*
System Name
*
System Representative Name
*
Mailing Address
*
City
*
State
*
Zip Code
*
Phone Number
*
Fax Number
Email Address
*
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 training expenses are expected to exceed $2,000 per operator.
Operators for Approval
*
Name of Operator
Role:
Certified?
Operator 1
Primary
Backup
Yes
No
Operator 2
Primary
Backup
Yes
No
Operator 3
Primary
Backup
Yes
No
Operator 4
Primary
Backup
Yes
No
Operator 5
Primary
Backup
Yes
No
Operator 6
Primary
Backup
Yes
No
Operator 7
Primary
Backup
Yes
No
I certify that the information provided in this application is true and complete to the best of my knowledge.
*
Yes
System Representative's Signature
*
Date
*
-
Month
-
Day
Year
Date Picker Icon
Please verify that you are human
*
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