Exceptions forms must be completed and submitted to the Department of Health (DOH) with the Annual Summary Report per WAC 246-290-490(4)(b)(iii). Complete and submit a new Exception form for each: New exception granted in report year, including exceptions granted in response to a completed forms to DOH compliance action, even if you’ve already sent manually DOH. Exception granted before report year, if the water system previously submit an didn’t Exceptions form to DOH. Use the and features to address exceptions granted in previous Edit, Renew, Cancel to submit a new form to extend the date of an reporting years. You don’t need “old” exception. submit blank forms. submit forms telling us that new new Don’t save or Don’t save or you grant any exceptions in the current reporting year. didn’t Part 1: Public Water System (PWS) Information PWS ID: PWS Name: County: Part 2: Premises Information Name of Premises Service Address Premises Type or Category Refer to Table 9 – of WAC 246-290-490(4)(b) Additional information or comments (to help explain why exception is appropriate): Part 3: Information Regarding Exception to Premises Isolation Enter dates in MM/DD/YYYY format. a. Date of Hazard Evaluation b. Date Exception Granted or Renewed c. Expiration Date of Exception d. Date of Next Hazard Evaluation Part 4: Justification for not Requiring Premises Isolation Using AG, RPBA, or RPDA
Exceptions forms must be completed and submitted to the Department of Health (DOH) with the Annual Summary Report per WAC 246-290-490(4)(b)(iii). Complete and submit a new Exception form for each: New exception granted in report year, including exceptions granted in response to a DOH compliance action, even if you’ve already sent manually completed forms to DOH. Exception granted before report year, if the water system didn’t previously submit an Exceptions form to DOH. Use the Edit, Renew, and Cancel features to address exceptions granted in previous reporting years. You don’t need to submit a new form to extend the date of an “old” exception. Don’t save or submit blank new forms. Don’t save or submit new forms telling us that you didn’t grant any exceptions in the current reporting year. Part 1: Public Water System (PWS) Information PWS ID: PWS Name: County: Part 2: Premises Information Name of Premises Service Address Premises Type or Category – Refer to Table 9 of WAC 246-290-490(4)(b) Additional information or comments (to help explain why exception is appropriate): Part 3: Information Regarding Exception to Premises Isolation Enter dates in MM/DD/YYYY format. a. Date of Hazard Evaluation b. Date Exception Granted or Renewed c. Expiration Date of Exception d. Date of Next Hazard Evaluation Part 4: Justification for not Requiring Premises Isolation Using AG, RPBA, or RPDA
331-156-F.docx