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Drinking Water FormsWater, Wastewater & Wetlands: Drinking Water Forms
Certified Operators
Board of Certification of Operators of Drinking Water Facilities Board of Certification Website Application form for TCH Approval from Board of Certification (BoC) Website and other BoC Forms Revised October 2005 MCSSA Operator Reimbursement Application Revised October 2005. Certified Operator Compliance Notice Revised November 2009. Certified Operator Directory Form Use this form if you are a Massachusetts certified operator and want to be listed in the Contract Operator Directory, or if you are a contract operator company and want to be listed in the Contract Operator Company Directory. Updated June 2011. Contract Operator Inspection Form Revised February 2007. Certified Operator Termination Notice Revised February 2007. Certified Operator Termination Rescission Notice Revised February 2007. System Staffing and Comprehensive Operations Plan February 2007. Back to Drinking Water Forms index Water, Wastewater & Wetlands: Drinking Water Forms
Consumer Confidence Reports
Consumer Confidence Report (CCR) Certification Form Revised February 2011. Back to Drinking Water Forms index Water, Wastewater & Wetlands: Drinking Water Forms
Cross Connections
Cross-Connection Control Program Plan for Community Public Water Systems with Population > 3,300 Template for preparing a Cross Connection Control Program Plan for Community PWS with a population of 3,300 or more. This template is the official MassDEP form to satisfy the requirements of 310 CMR 22.22(3)(b). January 2012. Cross-Connection Survey Report Form Updated July 2011. Inspection and Maintenance Report Form Updated July 2011. Repair and Re-test Report Form Updated July 2011. BRP WS 09 - Backflow Device Design Data Sheet ATTENTION: This permit application is no longer required. Please contact your local water authority for instructions on the submittal of plans for the installation of backflow prevention devices (RPBP) or assemblies (DCVA). BRP WS 10 - Cross Connection Certification Certification or Certification Renewal as a Backflow Prevention Device Tester or Cross Connection Surveyor. July 2001. Back to Drinking Water Forms index Water, Wastewater & Wetlands: Drinking Water Forms
Distribution System Modifications
BRP WS 32 - Distribution Modifications for Systems that serve more than 3,300 people Revised July 2001. BRP WS 33 - Distribution Modifications for Systems that serve 3,300 people or less Revised January 2011. Back to Drinking Water Forms index Water, Wastewater & Wetlands: Drinking Water Forms
Emergency Response
Emergency Response Plan Compliance Checklist Public water systems should complete and return this checklist to the appropriate MassDEP Regional Office by December 31, 2009. May 2009. Emergency Response Checklist This checklist, or a similar reporting form if a PWS already has one, should be completed for all levels of emergency and for Level III, IV, or V emergencies submitted to MassDEP together with the Emergency Response Report (After Action Report) below. March 2010. Emergency Response Report (After Action Report) To be completed and submitted to MassDEP following a water supply emergency incident. May 2009. Water Treatment Chemical Feed System Control and Alarm Testing Log Revised March 2010. Back to Drinking Water Forms index Water, Wastewater & Wetlands: Drinking Water Forms
Ground Water Rule
GWR A - Log Credit Determination Revised November 2011. GWR B - Immediate & Long-Term Response to Fecal Contamination Revised November 2011. GWR C - Representative Triggered Monitoring (OPTIONAL) Revised July 2009. This is an OPTIONAL form. GWR D - Request for 4-log Certification - Chlorination Revised October 2009. Application for all public water systems wishing to obtain MassDEP certification for 4-log virus treatment. This form is only for those PWSs who believe their existing chlorination systems and contact time can achieve 4-log treatment for viruses. GWR CT1 - CT Determination for Ground Water Rule Systems Revised February 2010. Public water systems must use this form unless directed to use GWR CT2. GWR CT2 - CT Determination for Ground Water Rule Systems Revised February 2010. GWR CT2 is only for public water suppliers that do not continuously measure flow or chlorine residual. MassDEP approval is required before using this form. GWR MF - Indirect Integrity Testing for Membrane Filtration Revised February 2012. Public water systems must use this form if the system uses membrane filtration capable of removing 4-log viruses and if the final turbidity value is greater than 0.15 NTU. Back to Drinking Water Forms index Water, Wastewater & Wetlands: Drinking Water Forms
Ground Water Under the Direct Influence of Surface Water (GWUDI)
Community Public Water System GWUDI Exemption Application Community public water systems must complete this application to determine if their groundwater source is exempt from microscopic particulate analysis (MPA) testing and the requriements of the Surface Water Treatment Rule (SWTR). Back to Drinking Water Forms index Water, Wastewater & Wetlands: Drinking Water Forms
Laboratory Analytical
Forms used by laboratories and certified operators for reporting the results of laboratory analytical testing of public water supplies to MassDEP. MassDEP Identified Sampling Location Numbers Revised December 2011. Testing Requirements for Public Water Systems - Summary Revised December 2003. Asbestos Revised May 2007. Bacteriological report Revised November 2009. Bromate Revised May 2007. Bromide Revised May 2007. Chlorine Revised May 2007. Chlorite/Chlorine Dioxide Revised May 2007. DBPR Compliance Revised May 2007. DBPR Treatment Technique (TT) Compliance Revised July 2009. Revised August 2007. Haloacetic Acids Revised July 2007. Inorganics Revised May 2007. Nitrate Revised May 2007. Nitrite Revised May 2007. PCE Revised May 2007. Perchlorate Revised October 2007. Radionuclides Revised January 2008. Radionuclide Photon Activity Report Revised January 2008. Uranium Guidance for Radionuclides Form Revised July 2002. Secondary Contaminants Revised July 2007. Synthetic Organic Compounds Revised February 2008. Sodium Report Revised May 2007. Total Organic Carbon (TOC) Revised May 2007. Trihalomethanes Revised July 2007. VOCs regulated and unregulated Revised October 2007. Back to Drinking Water Forms index Water, Wastewater & Wetlands: Drinking Water Forms
Lead and Copper
Certification of Consumer Notice of Lead Tap Water Monitoring Results (Lead & Copper Rule) Revised June 2010. DW LCR-COC - Home Sampling for Lead and Copper Revised November 2006. DW LCR-WQP A & B - Water Quality Parameter Analysis Revised February 2008. DW LCR-C, D & E - Lead and Copper Analysis Report & 90th Percentile Compliance Report Revised May 2007. DW LCR-A and LCR-B Revised March 2006. DW LCR - Lead and Copper Sampling Plan Change Form Revised March 2004. DW LCR - Lead and Copper Sampling Tiers Revised April 2005. DW LCR-SN - Lead and Copper Compliance Sampling Program: School Results Revised August 2007. Identifying Sites for Lead and Copper Sampling - Preparing a Sampling Plan and Materials Survey Worksheets Revised August 2007. DW LCR-HN - Lead and Copper Compliance Sampling Program: Homeowner Results Revised March 2010. DW LCR - Consecutive Systems Lead and Copper - Sampling Reduction Request Revised October 2004. Lead Service Line Replacement Program: Work Notice Form - First Notice Revised August 2007. Lead Service Line Replacement Program Work Notice Form - Second Notice Revised August 2007. Lead Service Line Replacement Program - Summary table Revised August 2007. Lead Service Line Replacement Program - Lead test result above the action level Revised October 2005. Lead Service Line Replacement Program - Lead test result below the action level Revised August 2007. Back to Drinking Water Forms index Water, Wastewater & Wetlands: Drinking Water Forms
Monitoring Waivers
Asbestos in Distribution System Exemption Form Revised July 2007. Community Groundwater Exemption Application Revised March 2003. Monitoring Waiver Application for 2011-2013 Compliance Period Revised June 2011. Back to Drinking Water Forms index Water, Wastewater & Wetlands: Drinking Water Forms
Monthly And Daily Reporting
Chemical Addition Report Revised May 2007. Coliform Bacteria Level 1 Assessment Form Revised October 2011. Form A: Source Water Quality Conditions for Unfiltered Systems Revised May 2007. Form B: CT Determination for Unfiltered Systems - Monthly Report to MassDEP Revised May 2007. Form C: CT Determination for Unfiltered Systems - Monthly Report to MassDEP Revised May 2007. Form E: Compliance Determination - Unfiltered Systems - Monthly Report to MassDEP Revised May 2007. Form F: Turbidity Data Sheet for Filtered Systems Revised May 2007. Form G: Compliance Determination - Filtered Systems - Monthly Report to MassDEP Revised May 2007. Form H: CT Determination for Filtered Systems - Monthly Report to MassDEP Revised May 2007. Form I: CT Determination for Filtered Systems - Monthly Report to MassDEP Revised May 2007. Form J: Turbidity - Individual Filter Monitoring Revised May 2007. LT2-SWTRs Revised May 2008. PWS Monthly Storage Tank Inspection Log Applies to all finished drinking water storage tanks and structures. August 2010 Back to Drinking Water Forms index Water, Wastewater & Wetlands: Drinking Water Forms
New Source Approvals
BRP WS 13 - Approval to Site a Source and Conduct a Pumping Test for a Source less than 70 Gallons per Minute Revised December 2010. BRP WS 15 - Approval of Pumping Test Report and to Construct a Source Less Than 70 Gallons per Minute Revised June 2008. BRP WS 17 - Approval to Site a Source and Conduct a Pumping Test for a Source Greater Than 70 Gallons per Minute Revised December 2010. BRP WS 19 - Approval of Pumping Test Report for Source of 70 Gallons per Minute or Greater Revised June 2008. BRP WS 20 - Approval to Construct a Source of 70 Gallons per Minute or Greater Revised June 2008. BRP WS 37 - Approval of Transient Non-Community Source Less than 7 Gallons per Minute Revised Dec 2010. Back to Drinking Water Forms index Water, Wastewater & Wetlands: Drinking Water Forms
New Technology Approvals
BRP WS 11 - Minor Technology Approval, no field test required Revised October 2005. BRP WS 12 - Major Technology Approval, field test required Revised October 2005. BRP WS 27 - New Technology - 3rd Party Approval Revised October 2005. BRP WS 28 - New Technology Vending Site/Source Revised October 2005. BRP WS 31 - New Technology - Vending Machines, POU/POE Devices Revised October 2005. Back to Drinking Water Forms index Water, Wastewater & Wetlands: Drinking Water Forms
Public Water System Modifications (Land, Source, or System)
BRP WS 26 - Sale or Acquisition of Land for Water Supply Purposes Revised October 2005. BRP WS 36 - Abandonment of Water Source Revised October 2005. Declassification/Reclassification of Public Water System Revised October 2005. Back to Drinking Water Forms index Water, Wastewater & Wetlands: Drinking Water Forms
Source Protection
Determination of Threat to Public Water Supplies Due to Beaver and Muskrat Revised February 2007. Form to Report Protocol for Awareness of New or Expanded Watershed Projects Revised March 2007. Back to Drinking Water Forms index Water, Wastewater & Wetlands: Drinking Water Forms
Statistical Reporting
2011 Annual Statistical Reporting via eDEP The 2011 ASR is now available. Your proofed eDEP accounts from last year's filing will provide you access to this year's eASR. The deadline for submitting the 2011 ASR is March 23, 2012. Instructions for electronic Annual Statistical Reporting (eASR) Instruction set for filling out and submitting your 2011 electronic Annual Statistical Report through eDEP. Includes instructions for applying for a proof, application navigation, saving, sharing, printing and submitting your eASR. Also includes form specific instructions for each section of the eASR. Worksheet - Confidently Estimated Use Excel spreadsheet for calculating confidently estimated use volume for 2011 Annual Statistical Report Worksheet - Estimating Population for RGPCD Excel spreadsheet for calculating populaton for use in 2011 Annual Statistical Report (Water Management Act Annual Report - Distribution). Revised January 2012. Back to Drinking Water Forms index Water, Wastewater & Wetlands: Drinking Water Forms
Underground Injection Control
Underground Injection Control Forms Well type descriptions, eDEP online filing options, and downloadable forms. Back to Drinking Water Forms index Water, Wastewater & Wetlands: Drinking Water Forms
Vending Machines
Also see Forms BRP WS 28, New Technology Vending Site/Source, and BRP WS 31, New Technology - Vending Machines, POU/POE Devices, under New Technology Approvals above. BRP WS 30 - Site Vending Machine Approval Revised October 2005. BRP WS 35 - Permit to Install Multiple Vending Machines Revised October 2005. Back to Drinking Water Forms index Water, Wastewater & Wetlands: Drinking Water Forms
Water Management Act Forms
Annual Reports, Water Audit, Water Conservation & Restriction, Water Management Act Back to Drinking Water Forms index Water, Wastewater & Wetlands: Drinking Water Forms
Water Treatment Plants
BRP WS 21 - Approval to Conduct Pilot Study Revised June 2009. BRP WS 22 - Approval of Pilot Study Report Revised June 2009. BRP WS 23, 24 - Approval to Construct a Water Treatment Facility Revised October 2005. BRP WS 25 - Approval of Treatment Facility Modification Revised October 2005. BRP WS 29 - Water Treatment - Chemical Addition Retrofit of Water Systems Serving More than 3,300 People Revised January 2011. BRP WS 34 - Water Treatment - Chemical Addition Retrofit of Water Systems Serving Less than 3,300 People Revised August 2001. Water Supply Facility Checklist for Potassium Hydroxide (KOH) or Sodium Hydroxide (NaOH) for Permit Review/Approval Revised May 2009. Water Supply Facility Checklist for Hypochlorination Using Sodium Hypochlorite (NaOCl) or Calcium Hypochlorite (Ca(OCl)2) for Permit Review/Approval Revised June 2009. Water Supply Facility Checklist for Chlorination Using Cl2 Gas for Permit Review/Approval Revised May 2010. Water Supply Facility Checklist for Fluoridation Using Sodium Fluoride Saturator for Permit Review/Approval Revised June 2010. Water Supply Facility Checklist for Hydrofluosilicic or Fluorosilicic Acid (H2SiF6) for Permit Review/Approval Revised July 2011. Water Supply Facility Checklist for Various Forms of Phosphate Compounds Used for Corrosion Control and Sequestering for Permit Review/Approval Revised August 2011. Water Supply Facility Checklist for Ultraviolet (UV) Disinfection for Permit Review/Approval Revised January 2012. Back to Drinking Water Forms index Water, Wastewater & Wetlands: Drinking Water Forms
Well Drillers
Well Completion Report Request Revised August 2010. Well Driller Forms General forms, monitoring reports, closed loop wells, decommissioned wells, hydrofracture wells, deepening wells, and addendum. Revised May 2010. Well Driller Re-Certification The January-December 2012 Well Driller Re-Certification form was mailed in November 2011 to all certified well drillers. It is to be completed by all well drillers currently certified and doing work in Massachusetts. If you are a driller not previously certified in Massachusetts, please contact Steve Hallem at 617-292-5681 or by email to stephen.hallem@state.ma.us. Back to Drinking Water Forms index Water, Wastewater & Wetlands: Drinking Water Forms
Zone 2 Determinations
BRP WS 07 - Zone 2 Pumping Test Revised October 2005. BRP WS 08 - Zone 2 Approval Revised October 2005. |
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