3900-FM-BSDW0105
6/2016
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
WATER AND WASTEWATER OPERATOR CERTIFICATION PROGRAM
CHAPTER 302 AVAILABLE OPERATOR REPORT
Title 25 Pa. Code § 302.1202(c) requires that owners of public water systems or wastewater systems report to the Department
within 10 days any changes (addition, loss, replacement) to their available operators or the operator-in-responsible-charge. For
loss or replacement, please include the employment end date for any operator no longer employed by your system. For any new
operators or changes to an operator’s class/subclasses, please also indicate whether the individual is an operator-in-responsiblecharge (ORC).
Please print all information and submit this form to:
You should also retain a copy for your records.
PA Department of Environmental Protection
Re: Chapter 302 AORs
P.O. Box 8467
Harrisburg, PA 17105-8467
Facility Name:
Facility ID No.:
Facility Address:
System Classification:
Facility City, State,
Zip:
PWS or NPDES
Permit No.:
Facility Phone No.:
Municipality:
Facility Email
Address:
County:
AVAILABLE OPERATORS (use an additional sheet if necessary)
Client ID
Certificate
No.
Name
CIRCUIT RIDER SYSTEM
Yes
Class &
Subclasses
Employment
Start Date
Employment
End Date
ORC
No
Name of Circuit Rider
Business
Address
City
Telephone
State
Zip
County
I am the legal owner or representative of this wastewater system. I have reviewed, and updated as necessary, the
information on this form and certify that it is true, complete, and accurate to the best of my knowledge.
Print Name
Title
Signature
Email
Date
Phone #
Rachel Carson State Office Building | 400 Market Street, PO Box 8467 | Harrisburg, PA 17105-8467
717.787.9633
www.dep.pa.gov