Revised XXXX

Small Untreated/Treated Water Systems Exam Registration and Certification Form

Operator Information:

Name:

Mailing Address:

City: State: Zip Code:

Work Phone No.: Contact Phone No.:

Email (required for online exam):

Years of Education Completed: Length of time as the drinking water operator: Years: Months:

Water System Information:

PWSID Number: Water System Name:

Please list the components of your system, including its water source, e.g. ground water, surface water.

Paper and pencil exam. Administered statewide twice per year in April and October.Online proctored exam. Available during normal testing center business hours.

I hereby certify that the information given by me is true and complete to the best of my knowledge.

Signature DateMaterials provided are public documents. Public documents are subject to release upon receiving requests for information.

Note: If you are NOT an operator, you must attach documentation of completing a DEC approved training course.

Note: The minimum education requirement is a high school diploma or G.E.D.

For ADEC Use Only: Payment:____________ Exam Type:__________ Location:_________________________________ Logon:___________________________________ Password:________________________________

Mail the completed application with the $150 exam registration/application fee, payable to the "State of Alaska", to: Alaska Department of Environmental Conservation Operator Training and Certification Program 410 Willoughby Avenue, Suite 303 P.O. Box 111800 Juneau, Alaska 99811-1800

Are you the drinking water system operator? Yes No

Small Untreated Water Systems Small Treated Water Systems

Anchorage Dillingham Fairbanks Glennallen KenaiKetchikanKodiak Palmer

Exam (Please Select One):

Exam Format (Please Select One):

Signature of Applicant:

Revised XXXX

Instructions for Completing the Application

Operator Information: • An email address is required if you opt for the proctored online certification exam option. Email is how

we will inform you of testing information. • A high school diploma or GED is the minimum educational requirement for Small Water Systems

certification. • If you are not an operator you must complete a DEC approved training course, e.g. DEC online

training course at www.dec.alaska.gov/water/opcert/onlinetraining.html. Documentation of course completion must be attached to the application.

Water System Information: • Please fill in your public water system identification (PWSID) number, if known, and the system name. • Please give an accurate description of your system.

Exam:

• The two options for taking the exam are the paper and pencil exam or the proctored online exam. o The paper and pencil exam is a multiple choice fill in the bubble exam and is administered

twice per year statewide in April and October. Please check our website at www.dec.alaska.gov/water/opcert/examdates.htm to ensure you meet the deadlines for application submission. In some special cases the exam can be administered on an as needed basis.

o The proctored online exam is similar to the paper and pencil exam. These exams are proctored and can only be taken at a DEC approved testing site. The approved testing sites are located in Anchorage, Dillingham, Fairbanks, Glennallen, Kenai, Ketchikan, Kodiak, and Palmer. More testing centers may be added if the need arises. You will be able to take the exam during the testing center’s normal business hours, all year round.

Fees: • The registration/application fee is $150 which must be included with the application. • If you choose the online exam option, a $30 testing center fee will be paid to the testing center at the time

of the exam. The testing center fee is $43 in Anchorage and Palmer and $50 in Fairbanks, Kenai, and Ketchikan.

Questions?Call us at (907) 465-1139 or email us at dec.opcert@alaska.gov.

• Select to take either the Small Untreated Water Systems or Small Treated Water Systems exam.