APPLICATION FOR WATER TREATMENT OPERATOR
EXAMINATION, RE-EXAMINATION, OR EXAMINATION FOR RESTRICTED CERTIFICATE
1. The Water Treatment Operator Examination, Re-Examination, or Examination for Restricted Certificate
Application form (SWRCB 8629 (6/2020)) must be filled out completely and postmarked by the final filingdate of the examination you wish to participate in. For an application to be considered complete, thefollowing must be provided:§Personal information (name, date of birth, high school information, last four digits of SSN, etc.)§Legible photocopies of an official transcript or certificate of completion (noting the number ofhours/units of training completed) if specialized training is a requirement for the examination you wishto take. These are the only acceptable forms of verification of completion of a course.
§Pay by check or money order made out to SWRCB-DWOCP. Do not send CASH.
§
Your original signature (preferably in blue ink)
ALL INFORMATION MUST BE PROVIDED ON THE APPLICATION AND
COURSEWORK VERIFIED EVEN IF YOU HAVE PREVIOUSLY SUBMITTED IT.
2. All minimum educational qualifications must be met by the final filing date of the exam you wish toparticipate in. If you have not completed the required specialized training course by the final filing date, yourapplication will be rejected.
3. If you are not sure of the requirements for a particular grade, either refer to the Regulations or contact thisoffice for clarification before submitting your application as EXAM FEES ARE NONREFUNDABLE.
Grade
Examination Fee
Re-Examination Fee*1$50.00$30.00
2$65.00$45.00
3$100.00$70.004$130.00$95.005$155.00$120.00*Re-exam fee applies if you are retaking the same grade level after notreceiving a passing grade on a previous exam.
4. Mail completed application, exam fee, and required attachments to:State Water Resources Control Board
Drinking Water Operator Certification Program
P.O. Box 944212
Sacramento, CA 94244-2120
PROPOSED GRADES 1-4 EXAM SITES
Concord
Los Angeles
FresnoOntario

Redding
Sacramento

San Diego
San JoseVentura

PROPOSED GRADE 5 EXAM SITES: Northern California/Southern California* Exam sites are in the general vicinity of the cities listed and are subject to change. Your preferred
exam site may change based on availability.
PHONE (916) 449-5611 // FAX (916) 449-5654 // EMAIL dwopcertprogram@waterboards.ca.gov
SWRCB 8629 (6/2020) / Treatment Exam Application

S:\DDW\EEC\Cert-Unit\WTOC Gold\Treatment

State of California

State Water Resources Control Board

GradeLevel

T1

Minimum Qualifications for Examination· High School or GED*
· High School or GED*

T2

AND
· One 36-contact-hour (3-unit) course in drinking water treatment.

· High School or GED

AND

T3· Two 36-contact-hour (3-unit) courses; one of which is in drinking water treatment

AND a second course in either drinking water treatment, wastewater treatment, ordistribution.

· A valid grade T3 operator certificate.

ANDT4· Three 36-contact-hour (3-unit) courses; two of which are in drinking water

treatment AND a third course in either drinking water treatment, wastewater
treatment, or distribution.

· A valid grade T4 operator certificate.

AND

T5· Four 36-contact-hour (3-unit) courses; two of which are in drinking water

treatment AND two additional courses in either drinking water treatment,
wastewater treatment, or distribution.
* High school/GED equivalency for T1 and T2 ONLY can be fulfilled with successful completion of the Basic Small
Water System Operations course developed by the State of California OR 1 year as an operator of a facility thatrequired an understanding of chemical feeds, hydraulic systems, and pumps.

For more information about specialized training, please visit our website at:www.waterboards.ca.gov/drinking_water/certlic/occupations/DWopcert.html.

SWRCB 8629 (6/2020) / Treatment Exam Application

State of California

State Water Resources Control Board

WATER TREATMENT OPERATORAPPLICATION FOR EXAMINATION OR RE-EXAMINATION
Operator number

Exam resultsDate received

Application approved for:

T1

T2

T3

Acknowledgement sent

T4T5

Approval sent

Application NOT approved:c Insufficient specialized training/verificationc High school/GED information incomplete
Comments

PLEASE DO NOT WRITE ABOVE THIS LINE
Please type or print legibly in ink.

1. PERSONAL INFORMATION (Legal Name)
LastFirst

MISuffix

Mailing address (number, street)

Date of Birth (mm/dd/yyyy)

Last 4-digits of Social Security Number

City

Work Telephone Number

Alternate Number: Home () or Cell ()StateZIP code

E-mail Address:ext.
Are you currently certified by the State of California as a
potable water treatment operator?

c Yesc No

Operator number

Grade / Expiration Date

2. EXAMINATION INFORMATION (Do Not send CASH) – Fees are NON-REFUNDABLE
Grade T1

Grade T2

Grade T3

Grade T4

Grade T5

c Exam $50

c Exam $65

c Exam $100

c Exam $130

c Exam $155

c Re-Exam $30

c Re-Exam $45

c Re-Exam $70

c Re-Exam $95

c Re-Exam $120

(if previously failed)(if previously failed)(if previously failed)(if previously failed)(if previously failed)

3. EXAM SITE (see cover page for a list of exam sites): ________________________________
Do you have an ADA Title I disability/impairment for which you may need assistance during the exam?

c Yes

c No

c Yes

c No

-If yes, please enclose a letter (from a professional authorized to make such assessments) that describes thespecific accommodations that will be required.
Please indicate if your religious beliefs prevent you from taking an exam on Saturday.
-If yes, please enclose a letter from your church stating that you are a member in good standing, and why
you cannot participate in a Saturday examination.

4. EDUCATION – Check one only
Did you graduate from high school?
Date Graduated (mm/yy)

c Yes

c NoIF NOT

Did you obtain a GEDcertificate?
If yes, provide a copy.

c Yes

c No

Name of high school

Location (city/state)

OR T1 or T2 applicants ONLY, if you do NOT have a high school diploma or GED certificate you must have1.

Successfully completed:
Basic Small Water System Operations course developed by the State of California?
c Yes c No (if yes, attach certificate of completion)

SWRCB 8629 (6/2020) / Treatment Exam Application

OR (see next page)

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T1 or T2 applicants ONLY, if you do NOT have a high school diploma or GED certificate.
2.

You must have one year of experience as an operator of a facility that requires an understanding of chemical feeds, hydraulicsystems, and pumps. This experience must be verified with a dated and signed letter from your supervisor on company
letterhead and a copy of your utility’s official job description.

From (mm/yy) To (mm/yy)

Name and Address of EmployerSupervisor’s Name

5. SPECIALIZED TRAINING (For grades 2–5 applicants only. Grade 1 applicants proceed to item 6.)
You must attach legible photocopies of OFFICIAL TRANSCRIPTS or CERTIFICATES OF COMPLETION as proof ofattainment of the required course work (certificates of completion must include the number of hours of instruction
completed). Please include only that information which verifies completion of the required course work. PLEASE NOTE:COPIES OF REPORT CARDS OR UNOFFICIAL TRANSCRIPTS ARE NOT ACCEPTABLE VERIFICATION OFCOURSE WORK.
Each course must be a minimum of 3 units or 36 hours of continuous formal instruction and must be provided byan organization accredited by the International Association of Continuing Education Training (IACET).
T2 applicants: One course in drinking water treatment
T3 applicants: Two courses, one of which must be in drinking water treatment, while the general course can be in drinking
water or wastewater treatment, drinking water or wastewater quality, or drinking water distribution
T4 applicants: Three courses, two of which must be in drinking water treatment, while the general course can be indrinking water or wastewater treatment, drinking water or wastewater quality, or drinking water distribution
T5 applicants: Four courses, two of which must be in drinking water treatment, while the two general courses can be in
drinking water or wastewater treatment, drinking water or wastewater quality, or drinking water distribution

6. SIGNATURE OF APPLICANT
I, the undersigned, certify that I am the above-named applicant; that all statements made on this application are true andcorrect; that I understand that any misrepresentations may result in ineligibility for the examination applied for or revocationof any certificate granted, pursuant to Section 106877 & Section 106878 of the Health and Safety Code.

____________________________________________________________________________________________________________________________________

Original Signature (Please Sign, NO Black Ink) (Photocopies NOT accepted)

Date

PRIVACY ACT DISCLOSURE
This information is required by the State Water Resources Control Board. The authority for maintaining the requested information is the California Code ofRegulations, Title 22, Section 63810. All information required on the application form must be provided by the applicant. Failure to complete any portion of thisform may result in delay or denial of eligibility for examination and/or certification. The information provided is used to evaluate the applicant’s eligibility for
examination as a water treatment facility operator. No transfers of this information are anticipated. For more information, or access to your records, contact theState Water Resources Control Board, Drinking Water Operator Certification Programs, PO Box 944212, Sacramento, CA 94244-2120; telephone number(916) 449-5611.

··Must be check or money order, made out to SWRCB-DWOCP (Do Not Send CASH)
Mail completed application, fee, and required attachments to:State Water Resources Control Board
Drinking Water Operator Certification Program
P. O. Box 944212
Sacramento, CA 94244-2120

SWRCB 8629 (6/2020) / Treatment Exam Application

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