What is the Designation of Water Operator in Responsible Charge?

It identifies the operator designated as being in responsible charge of a water system and collects system, owner, and operator information.

Who must sign the water operator designation form?

The form instructions say it must be completed and signed and dated by both the water system owner and the designated operator in responsible charge.

Do I need a notary for the water operator designation form?

No. The system owner and designated operator sign and date this form without a notary. The document does not specify a notarized attachment or sworn step.

Onondaga County, NY · Onondaga County

No notary required

Designation of Water Operator in Responsible Charge

Water system owners and designated operators complete this form to identify the operator in responsible charge and provide system and contact information.

At a glance

Issued by: City of Onondaga County · Onondaga County, Onondaga County, New York
Notarization: Not required: file this form without a notary.
Official source: onondaga.gov
Blank form: Download the PDF
Catalogued: Oct 5, 2026
Machine-readable: JSON record · about the forms index

What this form is

This form designates an operator in responsible charge for a water system. The system owner and designated operator complete it, providing system details, owner and operator contact information, and the operator’s certification grade and certificate number. Both parties must sign and date the form, then submit it to the New York State Department of Health.

Who needs it

The water system owner and the operator designated as being in responsible charge must complete, sign, and date this form.

How to submit it

Submit the completed form to the New York State Department of Health, Bureau of Public Water Supply Protection, Empire State Plaza, Corning Tower, Room 1110, Albany, NY 12237.

About notarization

This form is signed and dated by the system owner and designated operator without a notary; it does not specify a notarized attachment or sworn step.

How to submit this form

1
Download the Form
Download the Designation of Water Operator in Responsible Charge form.
2
Complete the Form
Type or print all requested information about the water system, owner, and operator. Do not provide a Social Security number.
3
Review and Sign
The system owner and designated operator must each sign and date the form.
4
Submit the Form
Send the completed form to the New York State Department of Health at the address printed on the form.

Frequently asked questions

What is the Designation of Water Operator in Responsible Charge?: It identifies the operator designated as being in responsible charge of a water system and collects system, owner, and operator information.
Who must sign the water operator designation form?: The form instructions say it must be completed and signed and dated by both the water system owner and the designated operator in responsible charge.
Do I need a notary for the water operator designation form?: No. The system owner and designated operator sign and date this form without a notary. The document does not specify a notarized attachment or sworn step.
How do I submit the water operator designation form?: Submit it to the New York State Department of Health, Bureau of Public Water Supply Protection, at the Albany address printed on the form.

Need something notarized?

This Designation of Water Operator in Responsible Charge doesn’t need a notary, but if you have another Onondaga County form that does, a commissioned online notary can help.