Dutchess County, NY · Dutchess County
Designation of Water Operator in Responsible Charge
This form designates the operator in responsible charge of a water system and is completed by the system owner and designated operator.
At a glance
- Issued by
- City of Dutchess County · Dutchess County, Dutchess County, New York
- Notarization
- Not required: file this form without a notary.
- Official source
- dutchessny.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
The form records the water system’s name, classification, contact details, owner information, and designated operator’s certification and contact details. The system owner and operator in responsible charge must complete the form, certify that its information is true, and sign and date it. The instructions say to submit the completed form to the New York State Department of Health.
Who needs it
A water system owner and the operator designated as responsible charge complete and sign this form for the referenced water system.
How to submit it
Submit the completed form to the New York State Department of Health, Bureau of Public Water Supply Protection, at the Albany address printed on the form.
About notarization
This document does not require a notary; the system owner and operator in responsible charge sign and date the form.
How to submit this form
- 1
Download the Form
Download the Designation of Water Operator in Responsible Charge form.
- 2
Complete the Form
The system owner and designated operator complete all requested system, owner, and operator information.
- 3
Sign and Date
The system owner and operator in responsible charge certify the information, then both sign and date the form.
- 4
Submit the Form
Submit the completed form to the New York State Department of Health at the Albany address printed on the form.
Frequently asked questions
- What does the Designation of Water Operator in Responsible Charge form do?
- It records the water system information and identifies its operator in responsible charge. The system owner and designated operator complete and sign the form.
- Who completes this water operator designation form?
- The form instructions say it must be completed by the water system owner and the designated operator in responsible charge. Both parties must sign and date it.
- Do I need a notary for the Designation of Water Operator in Responsible Charge?
- No. This form does not require a notary; the system owner and operator in responsible charge sign and date it.
- How do I submit the water operator designation form?
- Submit the completed form to the New York State Department of Health, Bureau of Public Water Supply Protection, at the Albany address printed on the form.