Utah CCC Program Administrator Renewal Application
NOTE: You can check certification details including Cert # and expiration date online at waterlink.utah.gov in the Public section.

Step 1 Meet annual CEU requirement
Step 2 Complete & submit this form
Step 3 Pay the $125 renewal fee for each certificate by going to our Payment Portal:
https://deq.utah.gov/drinking-water/payment-portal

(Paper application available upon request)
Email address *
First Name *
Last Name *
CCC PA Certification # *
Certification Expiration Date
MM
/
DD
/
YYYY
Date of Birth
MM
/
DD
/
YYYY
Mailing Address or PO Box *
City *
State *
Zip Code
Cell Phone
Format: 555-555-5555
Home Phone
Format: 555-555-5555
CEUs
NOTE: CEUs must be backflow/cross connection-related.

➡ Check your CEUs at https://deq.utah.gov/drinking-water/cross-connection-control-program-administrator in the CEU section.
How many CEUs have you acquired prior to expiration date (in units)? *
1.0 units = 10 hours (enter your answer in units)
Current Employment
Water System Name(s) *
If more than one, separate by a comma and a space.
Water System Number(s) *
If more than one, separate by a comma and a space. Check your water system number at waterlink.utah.gov.
Water System Email(s)
If more than one, separate by a comma and a space.
Work Phone
Format: 555-555-5555
Would you like to be available as a consultant or CCC Program Administrator of record for another drinking water system? *
If yes, provide a contact phone number:
Format: 555-555-5555
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