DDW-2025-001851

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Checklist Instructions:
☐Step 1 Complete a separate form for each discipline (Distribution or Treatment) for
which you are requesting reciprocity in Utah.
☐Step 2 Attach documentation of your certification.
Your certification must be current in your certifying state.
☐Step 3 Send the completed application to [e-mail]
 Reciprocity is reviewed and approved on a case-by-case basis.
Division of Drinking Water
Operator Certification
Program
P.O. Box 144830
Salt Lake City, UT 84114-4830
Phone: [phone]
E-mail: [e-mail]
DDWOpCert.utah.gov
Utah Division of Drinking Water
Operator Certification Program
RECIPROCITY APPLICATION
☐Step 4 Once your request has been approved, continue to Step 5.
☐Step 5 If reciprocity is granted, pay the $180 fee.
 Pay online at https://deq.utah.gov/drinking-water/dw-payment-portal#opcert
PERSONAL INFORMATION
First, Middle, Last Name (Mr. or Ms.): Certification #:
Email address: Date of Birth:
Home Address: Cell phone:
City: State: Zip: Home phone:
Certification Information
Current Certification
Discipline:
(Treatment or Distribution)
Utah Reciprocity Certification Request
Level: State:
Discipline:
(Treatment or Distribution)
OTHER LICENSES HELD
Level:
Plumber’s license, cross connection certificate, etc.
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EMPLOYMENT
Employer or Water System: Water System #:
Address: Phone:
City: State: Zip code: Fax:
Job Title:
Position Responsibilities:
Total years in position:
Total years w/ employer:
Are you a DRC* operator now? ☐Yes No☐
Total years as DRC* operator w/ employer:
*DRC (Direct Responsible Charge) – Active daily on-site charge and performance of operation duties. The person indirect responsible charge is generally an individual who
independently makes decisions during normal operation which can affect the sanitary quality, safety, and adequacy of water delivered to customers. In cases where only one
operator is employed by the system, this operator shall be considered to be indirect responsible charge. In cases where more than one operator is employed, more than one
operator may be in direct responsible charge.
DUPLICATE THIS PAGE IF YOU HAVE ADDITIONAL WATER-RELATED EXPERIENCE WITH OTHER EMPLOYERS
EDUCATION
What is the highest level of education you have completed?
GRADE SCHOOL: ☐ HIGH SCHOOL: ☐
COLLEGE GRADUATE: Degree: Major: Year:
Degree: Major: Year:
Applicant’s Signature: Date:
"By signing, I certify the above information is correct and complete.
I understand that all info might be verified by Drinking Water Staff."
☐
Proof of Citizenship

Under Utah State Law the Utah Department of Environmental Quality (DEQ) is required to verify the lawful presence
in the United States of an individual at least 18 years of age (includes sole proprietor doing business under assumed
name) who has applied for Water Operator certification or Backflow Technician certification. This law also applies for
renewal, reinstatement, and reciprocity applications. These documents will be confidential and not distributed
publicly.
Applicants for these certifications are required to notarize and attach the following documents:
 Complete and attach the form below
 Attach copy of your government issued photo ID
 Have the document notarized
Questions? Division of Drinking Water 195 North 1950 West P.O. Box 144830 Salt Lake City, UT 84114-4830 Phone: [phone] http://drinkingwater.utah.gov
I’ve already submitted a citizenship form.
U t a h Department of Environmental Q u a li t y
Certification Pursuant to U C A 6 3 G - 12 - 104 This paperwork must be:
 Completed prior to issuance of
certificate.

I, , hereby certify under penalty of perjury that I am:
Full Name
☐ a United States citizen. Must have copy of government issued photo ID attached.
OR
☐ a qualified alien as defined in 8 USC, Sec. 1641, and lawfully present in the United States.
Alien ID #:
Dated this day of , 20 .
Applicant’s Full Name:
Address:
Applicant’s Signature:
SUBSCRIBED AND SWORN to before me this day of , 20 . County: State: . Government Issued
PHOTO ID
(Place copy here)
(driver’s license, passport, etc.) (can attach copy, cut and tape, or print copy on back)
NOTARY PUBLIC
My commission expires: