This page, Public Notification Forms and Templates, is offered by
Massachusetts Department of Environmental Protection

Public Notification Forms and Templates

For Massachusetts' public drinking water systems.

There are circumstances that require Public Water Systems to provide language translations when posting Consumer Confidence Report (CCR), Public Education (PE), and Public Notice (PN) announcements. See Requirements For Language Translations for details.

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Certification Forms

Requirements for Language Translations

Public Notification Certification Form for Tier 1-3 violations (PDF 189.19 KB)

Public Notification Certification Form for Tier 1-3 violations (DOCX 144.39 KB)

Manganese Certification Form for Public Notice of a Manganese Health Advisory (PDF 17.26 KB)

Manganese Certification Form for Public Notice of a Manganese Health Advisory (DOC 62 KB)

Public Notification Certification Form for PFAS MCL violation (DOCX 143.05 KB)

Public Education Certification Form for PFAS without MCL violation (DOCX 142.98 KB)

Tier 1 Templates

PN Tier 1 Template: Nitrate (DOC 247 KB)

PN Tier 1 Template: Nitrate - Spanish translation (DOC 266 KB)

PN Tier 1 Template: Nitrate Failure to Take Confirmation Sample (DOC 249 KB)

PN Tier 1 Template: Coliform Rule (DOC 255.5 KB)

PN Tier 1 Template: Coliform Rule - Spanish Translation (DOC 252 KB)

PN Tier 1 Template: Waterborne Disease Outbreak (DOC 302.5 KB)

PN Tier 1 Template: Turbidity (DOC 229 KB)

PN Tier 1 Template: Chlorine Dioxide (DOC 209.5 KB)

PN Tier 1 Template: GWR Boil Order (DOCX 281.57 KB)

PN Tier 1 Template: GWR 4-log (DOC 225.5 KB)

PN Tier 1 Template: GWR Source Removed (DOC 228 KB)

PN Tier 1 Template: GWR Boil Order-NC (DOC 409.5 KB)

PN Tier 1 Template: Problem Corrected (DOC 112 KB)

Tier 2 Templates

PN Tier 2 Template: RTCR Failure of a Seasonal System to Complete Start-Up Procedures (2-1) (DOCX 58.73 KB)

PN Tier 2 Template: RTCR Failure to Perform any Level 1 or Level 2 Assessment that is Not Triggered by E. coli MCL Violations or the Related Corrective Actions (2-2.2) (DOCX 68.61 KB)

PN Tier 2 Template: RTCR Failure to Perform a Level 2 Assessment Triggered by an E. coli MCL Violation or the Related Corrective Actions (2-2.3) (DOCX 68.87 KB)

PN Tier 2 Template: Chemical or Radiological MCLs Notice (2-3) (DOCX 25.73 KB)

PN Tier 2 Template: Fluoride MCLs Notice (2-4) (DOCX 26.03 KB)

PN Tier 2 Template: Instructions SWTR Failure to Filter Notice (2-5) (DOCX 26.3 KB)

PN Tier 2 Template: SWTR Turbidity Exceedance Notice (2-6) (DOCX 27.51 KB)

PN Tier 2 Template: SWTR Disinfection Treatment Notice (2-7) (DOCX 27.86 KB)

PN Tier 2 Template: LCR Failure to Install/Maintain Corrosion Control (2-8) (DOCX 22.01 KB)

PN Tier 2 Template: LT2ESWTR Uncovered Finished Water Reservoir Treatment Notice (2-9) (DOCX 24.47 KB)

PN Tier 2 Template: LT2ESWTR Failure to Conduct Required Cryptosporidium Monitoring for Any Three Months Notice (2-10) (DOCX 20.07 KB)

PN Tier 2 Template: LT2ESWTR Filtered System Failure to Determine and Report Bin Classification Notice (2-11) (DOCX 25.21 KB)

PN Tier 2 Template: LT2ESWTR Unfiltered System Failure to Calculate and Report Mean Cryptosporidium Level Notice (2-12) (DOCX 25.46 KB)

PN Tier 2 Template: LT2ESWTR Filtered System Failure to Provide or Install an Additional Level of Treatment Notice (2-13) (DOCX 25.74 KB)

PN Tier 2 Template: LT2ESWTR Unfiltered System Failure to Achieve Required Inactivation Level Notice (2-14) (DOCX 25.92 KB)

PN Tier 2 Template: Instructions for LT2ESWTR Filtered System Failure to Achieve Required Treatment Credit Notice (2-15) (DOCX 25.32 KB)

PN Tier 2 Template: Instructions for LT2ESWTR Unfiltered System Failure to Maintain Required Inactivation Level Notice (2-16) (DOCX 25.58 KB)

PN Tier 2 Template: Instructions for LT2ESWTR Unfiltered System Failure to Install Second Disinfection Notice (2-17) (DOCX 25.73 KB)

PN Tier 2 Template: Stage 1 DBPR TTHM or HAA5 MCL Violation (2-18) (DOCX 19.04 KB)

PN Tier 2 Template: Stage 2 DBPR TTHM or HAA5 MCL Violation Instructions and PN (2-19) (DOCX 19.04 KB)

PN Tier 2 Template: Instructions for Filter Backwash Recycling Rule Treatment Technique Violation Notice (2-20) (DOCX 27.13 KB)

PN Tier 2 Template: Instructions for GWR Failure to Take Corrective Action within Required Time Frame Notice (2-21) (DOCX 28.33 KB)

PN Tier 2 Template: Instructions for GWR Failure to Maintain 4-log Treatment of Viruses Notice (2-22) (DOCX 27.6 KB)

PN Tier 2 Template: Instructions for Failure to Comply with the Conditions of an Exemption Notice (2-23) (DOCX 28.6 KB)

PN Tier 2 Template: Instructions for Monitoring Violation Elevated to Tier 2 Notice (2-24) (DOCX 27.88 KB)

PN Tier 2 Template: Public Notice for PFAS6 above 20 ng/L (2-25) (DOCX 101.4 KB)

PN Tier 2 Template: Combined Public Notice and Public Education for PFAS6 above 20 ng/L (2-26) (DOCX 133.58 KB)

PN Tier 2 Template and Instructions: Failure to Remove Lead Service Lines (2-27) (DOCX 35.33 KB)

Failure to remove the specified number of lead service lines in the specified period when required to do so in accordance with the 310 CMR 22.06B(5) is a TT violation requiring Tier 2 public notification (PN).