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Utah Water Operator Certification Program

CONTINUING EDUCATION UNIT (CEU)

INDIVIDUAL APPLICATION

 

Instructions: Attach copy of activity information and/or certificate of completion. Please print. For assistance, call (801) 536-4200.

 

Your Name and Address:

Name:

Address:

Phone:

Certification #: Last 4 digits of Social Security #:

   

Name of Employer
 

 

TRAINING ACTIVITY INFORMATION

Date(s) of Activity:

 

Location of Activity (name and address of institution):
 
 
 
 

 

Description of Activity:
 
 
 
 

Number of Hours Attended:
 

Instructor or Contact Person: Phone Number:

   

 

Send completed form to:

Department of Environmental Quality                                                                                    You may fax this form to (801) 536-4211

Division of Drinking Water

Operator Certification Program

150 North 1950 West

P.O. Box 144830

Salt Lake City, Utah 84114-4830