Application to Designate a Surrogate Sampling Point
Name of Beach (Sampling Point) to Use a Surrogate (Operator #1): _________________________________________________________________________
Sampling Point to be Used as a Surrogate (Operator #2): ___________________________
Body of Water: _____________________________ Date of Submittal: _______________
Distance from Beach to Surrogate Sampling Point: ________________________________
Is the beach using the surrogate sampling point separated from the surrogate in any way, including but not limited to jetties, creeks, streams, peninsulas, or stormwater outfalls?  YES / NO (circle one)   If yes, list barrier type: ___________________________________

Has either the surrogate or the beach to use the surrogate ever experienced an exceedance? YES / NO (circle one)   If yes, list all exceedances (dates and levels):_________________
_________________________________________________________________________
_________________________________________________________________________

By signing this form, the operator of the beach utilizing the surrogate sampling point states that he/she understands the following:
•	At any time the results of a bacterial test exceed the levels in 105 CMR 445.030, all beach operators using a surrogate sampling point must comply with 445.040.
•	The beach operator utilizing the surrogate sampling point will be equally responsible for the costs of testing, monitoring, and analysis.
•	The Board of Health or the Massachusetts Department of Public Health may require any or all beach operators to discontinue use of the surrogate sampling point at any time the bathing waters are found to be unfit, subject to contamination as to constitute a menace to public health, or do not provide sufficient protection to protect public health per 105 CMR 445.000.

Operator #1 Name/Signature:__________________________ Date: _________________
Operator #1 Address: ________________________________ Tel: __________________
Operator #2 Name/Signature:__________________________Date: _________________
Operator #2 Address: ________________________________ Tel: __________________
For Board of Health Use Only

Board of Health Member/Agent: ______________________________________________
APPROVED / DENIED (circle one)     If Denied, Reason: _________________________
_________________________________________________________________________
Date: _________________________

Instructions:

This form is to be used when two beach operators combine their individual beach sampling points, as described in 105 CMR 445.032(A)(5).
•	Name of beach (sampling point) to use a surrogate is the beach that will no longer be sampled.
•	Sampling point to be used as a surrogate is the combined sampling point for the two beaches.
•	Body of water is the specific name for the water body the beaches are physically located at (e.g. Buzzards Bay, Cotuit Bay, Turkey Hill Pond). Be as specific as possible.
•	The distance from beach to surrogate sampling point is the shoreline distance between the former sampling point (Operator #1) and the proposed surrogate sampling point for the two beaches (Operator #2). This distance can be derived using ArcMap, Google Earth, or similar mapping service.
•	If the sampling point for Operator #2 is being moved from a historical sampling point to accommodate a surrogate point then attach a map showing past and proposed sampling locations. Please keep in mind that the sampling point must be in the area of greatest bather load for the combined beach area.

This form is to be filled out in entirety before being valid. If there are any questions regarding the information required on this form, please contact the Board of Health or local Health Department.