Appendix J

Minnesota Department of Health Exam Application

MDH web site address to download exam:

http://www.health.state.mn.us/divs/eh/water/wateroperator/forms/opexamapp.pdf

Contact Information
Minnesota Department of Health (MDH)
Section of Drinking Water Protection
Certification Office
625 North Robert Street
P.O. Box 64975
St. Paul, MN 55164-0975

Mark Sloan – 651/201-4652

E-mail address: [email protected]

Noel Hansen –651/201-4690

E-mail address: [email protected]

Appendix J 1
 Notes:

Appendix J 2
 Section of Drinking Water Protection
P.O. Box 64975 Water Supply System Operator Exam Application
St. Paul, Minnesota 55164-0975
(Applicant Do Not Write in This Space)
Receptionist: 651-201-4700 Application Fee
Certification Office: 651-201-4696 or 651-201-4652 Fax: 651-201-4701
TDD: 651-201-5797 ; Minnesota Relay Service (Greater MN): 1-800-627-3529 Approved Rejected
Deposit Date
Read Instructions Carefully Before Completing Application
1. Application must be typewritten or printed in ink. Deposit Number
2. Answer all questions in full. Incomplete applications will not be Examination Date
processed, they will be returned to the submitter.
3. The application fee must accompany application. This fee does not Examination Results P F
include certificate issuance fee. Certification Fee
4. Check and money orders shall be made payable to (Minnesota
Department of Health)(MDH). Checks returned for nonpayment Deposit Date
will be charged a $20 fee (M.S. 332.50, Subd.2). Deposit Number
5. All application fees are non-refundable.
6. Submit the application and correct fee in the enclosed envelope. Certificate Issued
7. Applications must be postmarked no later than 15 days prior to Certificate Expires
the exam date.
8. Please read the enclosed Tennessen Warning about your rights Certificate Number
regarding the information you provide in this application.

Indicate your choice of location and date.

Exam Location: Exam Date:

To be eligible to take a certification exam, you must have hands-on operation experience (See certification
qualification rules on back page). Exam application fees are nonrefundable even if you are found to be ineligible.
If you have any questions about your eligibility, contact the certification office.

PLEASE CHECK (T)THE TYPE OF EXAM YOU ARE APPLYING FOR.

G $32 Water Supply System Operator Class A G $40 Reciprocity (You must submit a copy of your
(You must submit a copy of your current position current certificate).
description).

G $32 Water Supply System Operator Class B G $32 Water Supply System Operator Class D
G $32 Water Supply System Operator Class C G $32 Water Supply System Operator Class E

Last Name (print clearly or type) First Name (print clearly or type) Middle Initial

Home Mailing Address City State and Zip

Home Phone (include area code) Work Phone (include area code) Social Security Number

Your Current Employer

Complete Other Side

 TENNESSEN WARNING

Under Minnesota Statutes, section 13.41, information you provide on this application is private data until the
time you are licensed. Once you are licensed, the information becomes public data and will be part of the
agency’s permanent file.

You are not legally required to provide any of the requested information. Failure to provide the information,
however, will result in the denial of your application. Submitting false information is grounds for denying
your application or suspending, revoking, or taking other disciplinary action against your credential after it
is issued.

While your application is pending, the information you submitted, except your name and address, will not
be shared outside of the MDH except as authorized or required by law. In such cases, it may then be shared
with other, including the Office of the Attorney General, the Minnesota Department of Revenue and persons
contacted for purposes of verification or investigation. If the matter of your credentials becomes contested,
the information you submitted in this application may become public. When you become credentialed all
information in this application becomes public, except your social security number, which remains private.

EDUCATION

Circle last grade completed

1 2 3 4 5 6 7 8 9 10 11 Graduated or GED (High School Equivalency)

College or University Dates Attended Major Certificate or Degree Received

(list separately) (AA, BS, etc.)

Complete Other Side

EXPERIENCE

List your Water and Wastewater operation experience. Give nature of duties and responsibilities.
(List Most Recent First)
1)
Employer: Length of Experience:
System or Organization Name: Hours Per Week
Position: From: /
Supervisor Name: Month Year

Supervisor Phone #: ( ) To: /

Describe Job Duties: Month Year

2)
Employer: Length of Experience:
System or Organization Name: Hours Per Week
Position: From: /
Supervisor Name: Month Year

Supervisor Phone #: ( ) To: /

Describe Job Duties: Month Year

3)
Employer: Length of Experience:
System or Organization Name: Hours Per Week
Position: From: /
Supervisor Name: Month Year

Supervisor Phone #: ( ) To: /

Describe Job Duties: Month Year

Do you need special testing accommodations such as a reader or sign language interpreter? YES NO
If yes, please specify.

I declare that all information provided is true and complete. I hereby acknowledge that I have read and
understand the information above.

Date Signature (Do not print)

Qualification Rules

9400.0700 CERTIFICATION OF SYSTEM AND FACILITY OPERATORS.

This is only a short summary of the Water Supply System Operator qualifications.
The complete Minnesota Water and Wastewater Treatment Operator Certification Rule is available on
http://www.revisor.leg.state.mn.us/arule/9400 , or by calling the certification office.

Subp. 2. Certification in particular class. An applicant who seeks certification must:

A. meet the qualifications for one of the classes specified in this part and take and pass an exam; or
B. meet the requirements for reciprocity under part 9400.1350.

Class A certificate. An applicant for a Class A certificate must:

A. have been certified as a Class B operator for at least two years; and
B. have:
(1) a high school diploma or equivalent with at least eight years experience in the operation, including
at least two years as a part of the management, of a Class A or B system or facility, or a similar industrial
facility; or
(2) a bachelor's degree from an accredited institution in chemical, civil, environmental, mechanical, or
sanitary engineering or in a physical or biological science, and submit satisfactory evidence of at least four
years experience in the operation, including at least two years as a part of the management, of a Class A or B
system or facility or a similar industrial facility.

Class B certificate. An applicant for a Class B certificate must:

A. have been certified as a Class C operator for at least one year; and
B. have:
(1) a high school diploma or equivalent with at least six years experience in the operation of a Class A,
B, or C system or facility, or a similar industrial facility; or
(2) a bachelor's degree from an accredited institution in chemical, civil, environmental, mechanical, or
sanitary engineering or in a physical or biological science, and submit satisfactory evidence of at least two
years experience in the operation of a Class A, B, or C system or facility, or similar industrial facility.

Class C certificate. An applicant for a Class C certificate must have:

A. a high school diploma or equivalent, with at least three years experience in the operation of a Class A,
B, C, or D system or facility, or similar industrial facility; or
B. a bachelor's degree from an accredited institution in chemical, civil, environmental, mechanical,
or sanitary engineering or in a physical or biological science, and submit satisfactory evidence of at least
one year experience in the operation of a Class A, B, C, or D system or facility, or similar industrial facility.

Class D certificate. An applicant for a Class D certificate must have a high school diploma or equivalent; and
B. have:
(1) at least one year experience in the operation of a Class A, B, C, or D system or facility,
or in a related field; or
(2) satisfactorily completed a postsecondary program of courses in water or wastewater technology
approved by the respective agency or department at an accredited institution.

Class E certificate. An applicant for a Class E certificate must have a high school diploma or equivalent; and
B. have:
(1) at least three months experience in the operation of a Class A, B, C, or D, or E system or facility, or in
a related field; or
(2) satisfactorily completed a postsecondary program of courses in water or wastewater technology
approved by the respective agency or department at an accredited institution.