State Form 47289 - Application For Wastewater Treatment Plant Operator Certification Examination Page 2
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4III. OPERATIONAL EXPERIENCE HISTORY-Must be completed for certification applicants, optional for apprentice applicants
List your current assignment first. Show all acceptable experience in wastewater treatment plants. “Acceptable experience” means employment in
the actual hands-on operation, maintenance, management, or supervision of a wastewater treatment plant. Acceptable experience shall be obtained
under the supervision of a certified operator or by otherwise demonstrating that your experience meets the requirements.
Date
Position Information
(Month/Year)
From:
To:
Position Title
Name of Facility
Class of
Location (City & State) of Facility
Facility
Hours Per Week
Cert.Op.in Responsible Charge/Facility
Type of Treatment/Average Flow
NPDES Permit Number
Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the
supervision of a certified operator)
Position Title
Name of Facility
Class of
Location (City & State) of Facility
Facility
Hours Per Week
Cert.Op.in Responsible Charge/Facility
Type of Treatment/Average Flow
NPDES Permit Number
Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the
supervision of a certified operator)
Position Title
Name of Facility
Class of
Location (City & State) of Facility
Facility
Hours Per Week
Cert.Op.in Responsible Charge/Facility
Type of Treatment/Average Flow
NPDES Permit Number
Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the
supervision of a certified operator)
Position Title
Name of Facility
Class of
Location (City & State) of Facility
Facility
Hours Per Week
Cert.Op.in Responsible Charge/Facility
Type of Treatment/Average Flow
NPDES Permit Number
Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the
supervision of a certified operator)
Position Title
Name of Facility
Class of
Location (City & State) of Facility
Facility
Hours Per Week
Cert.Op.in Responsible Charge/Facility
Type of Treatment/Average Flow
NPDES Permit Number
Daily Job Duties (be specific , include what percentage of your time is/was spent in hands-on operation at a WWTP under the
supervision of a certified operator)
Page 2 of 4
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