Massachusetts Department of Environmental Protection Bureau of Resource Protection Drinking Program – Consumer Confidence Report Certification For calendar year A. PWS Information Important: When filling out on PWS Name the computer, use only the tab key to move your City /Town cursor - do not The community water system named above use the return hereby certifies that its Consumer Confidence PWS ID# key. Report (CCR) was distributed to customers, appropriate agencies, and notices of availability Name have been given in compliance with 310 CMR 22.16A. Furthermore, the system certifies that Title the information contained in the report is correct and consistent with the compliance monitoring Phone # data previously submitted to MassDEP. I certify under penalty of law that I am the person Date authorized to fill out this form and the information contained herein is true, accurate, and complete to Signature of Party or Certified Operator the best of my knowledge and belief. B. Public Notice Certification CCR delivery by Is this system using this CCR to provide Tier 3 Public Notice? Yes No newspaper or postings does not What PN is included? Violation UCMR Other meet PN requirements. List other PN must be Did you have a consultation with MassDEP ? Yes No directly delivered Consultation date (by hand, land, electronic). The PN can be found on page of the CCR. Date of PN Occurrence I am reporting multiple Tier 3 PNs. I have listed the additional PN information at the end of this form. The public water system indicated above hereby affirms that a Tier 3 public notice has been provided within this CCR to consumers in accordance with 310 CMR 22.16(4) including: delivery, content, format requirements, notification deadlines, and that the public water system will meet future requirements for notifying new billing units and new customers of the violation. C. For Systems Selling Water to Other Community Water Systems If you did not sell water to another community PWS My system delivered the applicable information required at 310 CMR 22.16A(3), to the buying skip Section C. system(s) no later than April 1st of this year, or by the mutually agreed upon date specifically included in a written contract between the parties. D. Annual Cross Connection Education Is this CCR being used for your system’s annual cross-connection education? Yes No If no, what methods did you use to meet your annual CCCP requirements (citation)? Continued on next page
Massachusetts Department of Environmental Protection Bureau of Resource Protection – Drinking Program Consumer Confidence Report Certification For calendar year A. PWS Information Important: When filling out on the computer, use only the tab key to move your cursor - do not use the return key. PWS Name City /Town The community water system named above hereby certifies that its Consumer Confidence Report (CCR) was distributed to customers, appropriate agencies, and notices of availability have been given in compliance with 310 CMR 22.16A. Furthermore, the system certifies that the information contained in the report is correct and consistent with the compliance monitoring data previously submitted to MassDEP. I certify under penalty of law that I am the person authorized to fill out this form and the information contained herein is true, accurate, and complete to the best of my knowledge and belief. PWS ID# Name Title Phone # Date Signature of Party or Certified Operator B. Public Notice Certification CCR delivery by newspaper or postings does not meet PN requirements. PN must be directly delivered (by hand, land, electronic). Is this system using this CCR to provide Tier 3 Public Notice? Yes No What PN is included? Violation UCMR Other List other Did you have a consultation with MassDEP ? Yes No Consultation date The PN can be found on page of the CCR. Date of PN Occurrence I am reporting multiple Tier 3 PNs. I have listed the additional PN information at the end of this form. The public water system indicated above hereby affirms that a Tier 3 public notice has been provided within this CCR to consumers in accordance with 310 CMR 22.16(4) including: delivery, content, format requirements, notification deadlines, and that the public water system will meet future requirements for notifying new billing units and new customers of the violation. If you did not sell water to another community PWS skip Section C. C. For Systems Selling Water to Other Community Water Systems My system delivered the applicable information required at 310 CMR 22.16A(3), to the buying system(s) no later than April 1st of this year, or by the mutually agreed upon date specifically included in a written contract between the parties. D. Annual Cross Connection Education Is this CCR being used for your system’s annual cross-connection education? Yes No If no, what methods did you use to meet your annual CCCP requirements (citation)? Continued on next page