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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 for Lead 90th Percentile ALE, Open DOCX file, 37.02 KB (English, DOCX 37.02 KB)
Public Notification Certification Form for Tier 1-3 violations, Open PDF file, 189.19 KB (English, PDF 189.19 KB)

Public Notification Certification Form for Tier 1-3 violations, Open DOCX file, 144.39 KB (English, DOCX 144.39 KB)

Manganese Certification Form for Public Notice of a Manganese Health Advisory, Open PDF file, 17.26 KB (English, PDF 17.26 KB)

Manganese Certification Form for Public Notice of a Manganese Health Advisory, Open DOC file, 62 KB (English, DOC 62 KB)

Public Notification Certification Form for PFAS MCL violation, Open DOCX file, 149.08 KB (English, DOCX 149.08 KB)

Public Education Certification Form for PFAS without MCL violation, Open DOCX file, 142.98 KB (English, DOCX 142.98 KB)

Tier 1 Templates

PN Tier 1 Template: Nitrate, Open DOC file, 247 KB (English, DOC 247 KB)
PN Tier 1 Template: Nitrate - Spanish translation, Open DOC file, 266 KB (Spanish, DOC 266 KB)
PN Tier 1 Template: Nitrate Failure to Take Confirmation Sample, Open DOC file, 249 KB (English, DOC 249 KB)
PN Tier 1 Template: Coliform Rule, Open DOCX file, 360.12 KB (English, DOCX 360.12 KB)
PN Tier 1 Template: Coliform Rule - Spanish Translation, Open DOCX file, 202.53 KB (Spanish, DOCX 202.53 KB)
PN Tier 1 Template: Waterborne Disease Outbreak, Open DOC file, 270 KB (English, DOC 270 KB)
PN Tier 1 Template: Turbidity, Open DOC file, 254 KB (English, DOC 254 KB)
PN Tier 1 Template: Chlorine Dioxide, Open DOC file, 209.5 KB (English, DOC 209.5 KB)
PN Tier 1 Template: GWR Boil Order, Open DOCX file, 210.58 KB (English, DOCX 210.58 KB)
PN Tier 1 Template: GWR 4-log, Open DOC file, 160 KB (English, DOC 160 KB)
PN Tier 1 Template: GWR Source Removed, Open DOC file, 163 KB (English, DOC 163 KB)
PN Tier 1 Template: GWR Boil Order-NC, Open DOC file, 344 KB (English, DOC 344 KB)
PN Tier 1 Template: Problem Corrected, Open DOC file, 112 KB (English, DOC 112 KB)
PN Tier 1 Template: Lead Action Level Exceedance (for Community Systems), Open DOCX file, 93.63 KB (English, DOCX 93.63 KB)

PN Tier 1 Template: Lead Action Level Exceedance (for very small Community Systems), Open DOCX file, 90.87 KB (English, DOCX 90.87 KB)

PN Tier 1 Template: Lead Action Level Exceedance (for Non-Transient Non-Community Systems), Open DOCX file, 83 KB (English, DOCX 83 KB)

PN Tier 1 and PE Combined Template: Lead Action Level Exceedance (for Non-Transient Non-Community and very small Community Systems), Open DOCX file, 107.24 KB (English, DOCX 107.24 KB)

Tier 2 Templates

PN Tier 2 Template: RTCR Failure of a Seasonal System to Complete Start-Up Procedures (2-1), Open DOCX file, 94.7 KB (English, DOCX 94.7 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), Open DOCX file, 106.85 KB (English, DOCX 106.85 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), Open DOCX file, 106.29 KB (English, DOCX 106.29 KB)

PN Tier 2 Template: Chemical or Radiological MCLs Notice (2-3), Open DOCX file, 75.83 KB (English, DOCX 75.83 KB)

PN Tier 2 Template: Fluoride MCLs Notice (2-4), Open DOCX file, 76.28 KB (English, DOCX 76.28 KB)

PN Tier 2 Template: Instructions SWTR Failure to Filter Notice (2-5), Open DOCX file, 86.88 KB (English, DOCX 86.88 KB)

PN Tier 2 Template: SWTR Turbidity Exceedance Notice (2-6) , Open DOCX file, 119 KB (English, DOCX 119 KB)

PN Tier 2 Template: SWTR Disinfection Treatment Notice (2-7) , Open DOCX file, 85.86 KB (English, DOCX 85.86 KB)

PN Tier 2 Template: LCR Failure to Install/Maintain Corrosion Control (2-8) , Open DOCX file, 73.5 KB (English, DOCX 73.5 KB)

PN Tier 2 Template: LCR Temporary Loss/Change of Treatment (2-8a) , Open DOCX file, 73.08 KB (English, DOCX 73.08 KB)

PN Tier 2 Template: LCR Failure to Maintain Corrosion Control Treatment (2-8b), Open DOCX file, 73.42 KB (English, DOCX 73.42 KB)

PN Tier 2 Template: LT2ESWTR Uncovered Finished Water Reservoir Treatment Notice (2-9) , Open DOCX file, 86.27 KB (English, DOCX 86.27 KB)

PN Tier 2 Template: LT2ESWTR Failure to Conduct Required Cryptosporidium Monitoring for Any Three Months Notice (2-10) , Open DOCX file, 83.84 KB (English, DOCX 83.84 KB)

PN Tier 2 Template: LT2ESWTR Filtered System Failure to Determine and Report Bin Classification Notice (2-11), Open DOCX file, 85.46 KB (English, DOCX 85.46 KB)

PN Tier 2 Template: LT2ESWTR Unfiltered System Failure to Calculate and Report Mean Cryptosporidium Level Notice (2-12), Open DOCX file, 86.02 KB (English, DOCX 86.02 KB)

PN Tier 2 Template: LT2ESWTR Filtered System Failure to Provide or Install an Additional Level of Treatment Notice (2-13), Open DOCX file, 85.93 KB (English, DOCX 85.93 KB)

PN Tier 2 Template: LT2ESWTR Unfiltered System Failure to Achieve Required Inactivation Level Notice (2-14), Open DOCX file, 85.97 KB (English, DOCX 85.97 KB)

PN Tier 2 Template: Instructions for LT2ESWTR Filtered System Failure to Achieve Required Treatment Credit Notice (2-15), Open DOCX file, 86.06 KB (English, DOCX 86.06 KB)

PN Tier 2 Template: Instructions for LT2ESWTR Unfiltered System Failure to Maintain Required Inactivation Level Notice (2-16), Open DOCX file, 85.6 KB (English, DOCX 85.6 KB)

PN Tier 2 Template: Instructions for LT2ESWTR Unfiltered System Failure to Install Second Disinfection Notice (2-17) , Open DOCX file, 85.64 KB (English, DOCX 85.64 KB)

PN Tier 2 Template: DBPR TTHM and HAA5 MCL Violation - Instructions and PN (2-19), Open DOCX file, 134.26 KB (English, DOCX 134.26 KB)

PN Tier 2 Template: Stage 2 DBPR HAA5 MCL Violation (2-19.1), Open DOCX file, 129.57 KB (English, DOCX 129.57 KB)

PN Tier 2 Template: Stage 2 DBPR TTHM MCL Violation (2-19.2), Open DOCX file, 128.57 KB (English, DOCX 128.57 KB)

PN Tier 2 Template: Instructions for Filter Backwash Recycling Rule Treatment Technique Violation Notice (2-20) , Open DOCX file, 119.77 KB (English, DOCX 119.77 KB)

PN Tier 2 Template: Instructions for GWR Failure to Take Corrective Action within Required Time Frame Notice (2-21), Open DOCX file, 88.07 KB (English, DOCX 88.07 KB)

PN Tier 2 Template: Instructions for GWR Failure to Maintain 4-log Treatment of Viruses Notice (2-22), Open DOCX file, 120.73 KB (English, DOCX 120.73 KB)

PN Tier 2 Template: Instructions for Failure to Comply with the Conditions of an Exemption Notice (2-23), Open DOCX file, 120.58 KB (English, DOCX 120.58 KB)

PN Tier 2 Template: Instructions for Monitoring Violation Elevated to Tier 2 Notice (2-24), Open DOCX file, 119.64 KB (English, DOCX 119.64 KB)

PN Tier 2 Template: PFAS6 above the 20 ng/L MCL (2-25), Open DOCX file, 144.34 KB (English, DOCX 144.34 KB)

PN Tier 2 Template: Combined Public Notice Tier 2 and Public Education for PFAS6 above 20 ng/L (2-26), Open DOCX file, 134.73 KB (English, DOCX 134.73 KB)

PN Tier 2 Template: LCR Failure to Remove the Required Number of LSLs (2-27), Open DOCX file, 75.15 KB (English, DOCX 75.15 KB)

PN Tier 2 Template: LCRR Failure to Complete and/or Make Service Line Inventory Publicly Accessible (2-28), Open DOCX file, 60.66 KB (English, DOCX 60.66 KB)

Tier 3 Templates

Public Notification Template for Tier 3 Violations of Drinking Water Regulations, Open DOC file, 48 KB (English, DOC 48 KB)
Public Notice Tier 3 Template: Special Notice for Availability of UCMR Data, Open DOCX file, 69.59 KB (English, DOCX 69.59 KB)
PN Tier 3 Template: LCRR Failure to Report Initial Service Line Inventory to MassDEP , Open DOCX file, 69.08 KB (English, DOCX 69.08 KB)
PN Tier 3 Template: LCRR Failure to Certify Notification to Consumers Served by Known or Potential Service Line Containing Lead , Open DOCX file, 70.97 KB (English, DOCX 70.97 KB)

Templates for Non-Community Public Water Systems

Public Notification Templates for Non-Community Public Water Systems, Open DOC file, 107.5 KB (English, DOC 107.5 KB)

Templates for Water Treatment

Public Notification Template when Switching from Chlorine to Chloramines, Open DOCX file, 27.9 KB (English, DOCX 27.9 KB)

Templates for Manganese

PN Template for manganese levels between 0.30-1.0 for Community PWS, Open DOCX file, 38.83 KB (English, DOCX 38.83 KB)
PN Template for manganese levels greater than 1.0 for Community PWS, Open DOCX file, 61.01 KB (English, DOCX 61.01 KB)
PN Template for manganese levels between 0.30-1.0 for Non-Transient Non-Community PWS, Open DOCX file, 62.01 KB (English, DOCX 62.01 KB)
PN Template for manganese levels greater than 1.0 for Non-Transient Non-Community PWS, Open DOCX file, 58.85 KB (English, DOCX 58.85 KB)
PN Template for manganese levels greater than 0.30 for Transient Non-Community PWS with daycare center, Open DOCX file, 76.01 KB (English, DOCX 76.01 KB)
PN Template for manganese levels greater than 1.0 for Transient Non-Community PWS without daycare, Open DOCX file, 62.66 KB (English, DOCX 62.66 KB)

Public Education Templates

PE Template: PFAS Public Education Materials, Open DOCX file, 97.84 KB (English, DOCX 97.84 KB)

Cyanotoxins Public Notice Template for Infants and Pre-school Age Children, Open DOCX file, 69.64 KB (English, DOCX 69.64 KB)

Cyanotoxins Public Notice Template for Adults, Open DOCX file, 39.44 KB (English, DOCX 39.44 KB)

Guidance and Factsheets to Include with Public Notices

List of Affected Areas - MassDEP DWP Boil Order Template, Open DOCX file, 43.17 KB (English, DOCX 43.17 KB)
MassDEP DWP Factsheet - Guidance for Restaurant Establishments During a Boil Order, Open PDF file, 213.49 KB (English, PDF 213.49 KB)
MassDEP DWP Fact Sheet: Tips for Restaurant Establishments Handwashing During a Boil Order, Open PDF file, 244.79 KB (English, PDF 244.79 KB)
MassDEP DWP Factsheet - Drinking Water Contaminated with Bacteria, Open PDF file, 258.03 KB (English, PDF 258.03 KB)

Additional Public Notification Resources

FAQs: Drinking Water Public Notification
Fact Sheet: Drinking Water Public Notification

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