Level 1 Assessment Water System Name: Water System Number: Depending on the Person Responsible for Conducting and Documenting the Assessment, Select Option A, B or C Assessment Conducted and Assessment Conducted by Water System Assessment Conducted and Option A: Option B: Option C: Documented by Water System Representative Representative (must be Owner, Operator or PE) and Documented by Public Water Supply Section (must be Owner, Operator or PE) Documented by Public Water Supply Section Representative Representative [Complete Section 1 Only] [Complete Both Sections 1 and 2] [Complete Section 2 Only] Section 1: System Representative Information (must be Owner, Operator or PE) Name: Title: Date of On-site Assessment: Assessment Completion Date: Signature (Not Required for Option B): Phone Number: Email: Section 2: Public Water Supply Section Representative Information Name: Regional Office: Date of On-site Assessment: Assessment Completion Date: Signature: Number: Email: Date copy of assessment was sent to owner via Email or Mail: Comments: Please return this form to the Public Water Supply Section at the address below within 30 days of the Level 1 Assessment Trigger Date 1634 Mail Service Center, Raleigh, North Carolina 27699-1634 Attention: Coliform Rule Manager OR
Level 1 Assessment Water System Name: Water System Number: Depending on the Person Responsible for Conducting and Documenting the Assessment, Select Option A, B or C Option A: Assessment Conducted and Documented by Water System Representative (must be Owner, Operator or PE) [Complete Section 1 Only] Option B: Assessment Conducted by Water System Representative (must be Owner, Operator or PE) and Documented by Public Water Supply Section Representative [Complete Both Sections 1 and 2] Option C: Assessment Conducted and Documented by Public Water Supply Section Representative [Complete Section 2 Only] Section 1: System Representative Information (must be Owner, Operator or PE) Name: Title: Date of On-site Assessment: Assessment Completion Date: Signature (Not Required for Option B): Phone Number: Email: Section 2: Public Water Supply Section Representative Information Name: Regional Office: Date of On-site Assessment: Assessment Completion Date: Signature: Number: Email: Date copy of assessment was sent to owner via Email or Mail: Comments: Please return this form to the Public Water Supply Section at the address below within 30 days of the Level 1 Assessment Trigger Date 1634 Mail Service Center, Raleigh, North Carolina 27699-1634 Attention: Coliform Rule Manager OR
RTCR%20-%20Level%201%20Assessment%20Form_August%202016.docx