Exhibit G_NYSDOH Form 4204 (Designation of Water Operator in Responsible Charge).pdf

NEW YORK STATE DEPARTMENT OF HEALTH

Bureau of Public Water Supply Protection Empire State Plaza - Corning Tower Room 1110 Albany, NY 12237

(518) 402-7712

Designation of Water Operator in Responsible Charge

INSTRUCTIONS

1. Type or Print - No pencil/felt tip pen.

2. Form must be completed in its entirety.

3. Form must be completed by system owner and designated operator in responsible charge.

4. Form must be signed and dated by both parties.

DOH-4204 (04/01: interim revision 01/10

V E R I F I C A T I O N

Note: Read carefully before signing

I certify that all information provided in this form for designation of operator in responsible charge for the above referenced water system is true. I understand that misstatement of material facts may result in a violation of Subpart 5-4 of the State Sanitary Code.

Signed _____________________________________________________ Date ________/________/________ (System Owner)

Signed _____________________________________________________ Date ________/________/________ (Operator in Responsible Charge)

5. Submit to the New York State Department of Health.

1. System Name: 2. Classification of System: 3. System Phone:

4. System Address: (Street) (City) (State) (Zip)

S Y S T E M I N F O R M A T I O N

5. Owner's Name: (Last) (First) (MI)

7. Owner's Address: (Street) (City) (State) (Zip)

6. Home phone:

Work phone:

O P E R A T O R I N R E S P O N S I B L E C H A R G E I N F O R M A T I O N

9. NYS DOH Certificate #

12. Home phone

Work phone ( )

( )11. ORC's Name: (Last) (First) (MI)

13. ORC's Address: (Street) (City) (State) (Zip)

10. Grade of CertificationDo not provide Social Security number