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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- 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.
Table of Contents
Certification Forms
Open PDF file, 189.19 KB,
Public Notification Certification Form for Tier 1-3 violations
(English, PDF 189.19 KB)
Open DOCX file, 144.39 KB,
Public Notification Certification Form for Tier 1-3 violations
(English, DOCX 144.39 KB)
Open PDF file, 17.26 KB,
Manganese Certification Form for Public Notice of a Manganese Health Advisory
(English, PDF 17.26 KB)
Open DOC file, 62 KB,
Manganese Certification Form for Public Notice of a Manganese Health Advisory
(English, DOC 62 KB)
Open DOCX file, 143.05 KB,
Public Notification Certification Form for PFAS MCL violation
(English, DOCX 143.05 KB)
Open DOCX file, 142.98 KB,
Public Education Certification Form for PFAS without MCL violation
(English, DOCX 142.98 KB)
Tier 1 Templates
Open DOC file, 247 KB,
PN Tier 1 Template: Nitrate
(English, DOC 247 KB)
Open DOC file, 266 KB,
PN Tier 1 Template: Nitrate - Spanish translation
(Spanish, DOC 266 KB)
Open DOC file, 249 KB,
PN Tier 1 Template: Nitrate Failure to Take Confirmation Sample
(English, DOC 249 KB)
Open DOC file, 255.5 KB,
PN Tier 1 Template: Coliform Rule
(English, DOC 255.5 KB)
Open DOC file, 252 KB,
PN Tier 1 Template: Coliform Rule - Spanish Translation
(Spanish, DOC 252 KB)
Open DOC file, 302.5 KB,
PN Tier 1 Template: Waterborne Disease Outbreak
(English, DOC 302.5 KB)
Open DOC file, 229 KB,
PN Tier 1 Template: Turbidity
(English, DOC 229 KB)
Open DOC file, 209.5 KB,
PN Tier 1 Template: Chlorine Dioxide
(English, DOC 209.5 KB)
Open DOCX file, 281.57 KB,
PN Tier 1 Template: GWR Boil Order
(English, DOCX 281.57 KB)
Open DOC file, 225.5 KB,
PN Tier 1 Template: GWR 4-log
(English, DOC 225.5 KB)
Open DOC file, 228 KB,
PN Tier 1 Template: GWR Source Removed
(English, DOC 228 KB)
Open DOC file, 409.5 KB,
PN Tier 1 Template: GWR Boil Order-NC
(English, DOC 409.5 KB)
Open DOC file, 112 KB,
PN Tier 1 Template: Problem Corrected
(English, DOC 112 KB)
Tier 2 Templates
Open DOCX file, 85.77 KB,
PN Tier 2 Template: RTCR Failure of a Seasonal System to Complete Start-Up Procedures (2-1)
(English, DOCX 85.77 KB)
Open DOCX file, 94.45 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)
(English, DOCX 94.45 KB)
Open DOCX file, 98.93 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)
(English, DOCX 98.93 KB)
Open DOCX file, 74.42 KB,
PN Tier 2 Template: Chemical or Radiological MCLs Notice (2-3)
(English, DOCX 74.42 KB)
Open DOCX file, 74.86 KB,
PN Tier 2 Template: Instructions SWTR Failure to Filter Notice (2-5)
(English, DOCX 74.86 KB)
Open DOCX file, 75.04 KB,
PN Tier 2 Template: SWTR Turbidity Exceedance Notice (2-6)
(English, DOCX 75.04 KB)
Open DOCX file, 74.75 KB,
PN Tier 2 Template: SWTR Disinfection Treatment Notice (2-7)
(English, DOCX 74.75 KB)
Open DOCX file, 72.1 KB,
PN Tier 2 Template: LCR Failure to Install/Maintain Corrosion Control (2-8)
(English, DOCX 72.1 KB)
Open DOCX file, 76.81 KB,
PN Tier 2 Template: LT2ESWTR Uncovered Finished Water Reservoir Treatment Notice (2-9)
(English, DOCX 76.81 KB)
Open DOCX file, 72.9 KB,
PN Tier 2 Template: LT2ESWTR Failure to Conduct Required Cryptosporidium Monitoring for Any Three Months Notice (2-10)
(English, DOCX 72.9 KB)
Open DOCX file, 74.41 KB,
PN Tier 2 Template: LT2ESWTR Filtered System Failure to Determine and Report Bin Classification Notice (2-11)
(English, DOCX 74.41 KB)
Open DOCX file, 74.87 KB,
PN Tier 2 Template: LT2ESWTR Unfiltered System Failure to Calculate and Report Mean Cryptosporidium Level Notice (2-12)
(English, DOCX 74.87 KB)
Open DOCX file, 84.25 KB,
PN Tier 2 Template: LT2ESWTR Filtered System Failure to Provide or Install an Additional Level of Treatment Notice (2-13)
(English, DOCX 84.25 KB)
Open DOCX file, 84.47 KB,
PN Tier 2 Template: LT2ESWTR Unfiltered System Failure to Achieve Required Inactivation Level Notice (2-14)
(English, DOCX 84.47 KB)
Open DOCX file, 84.61 KB,
PN Tier 2 Template: Instructions for LT2ESWTR Filtered System Failure to Achieve Required Treatment Credit Notice (2-15)
(English, DOCX 84.61 KB)
Open DOCX file, 86.09 KB,
PN Tier 2 Template: Instructions for LT2ESWTR Unfiltered System Failure to Maintain Required Inactivation Level Notice (2-16)
(English, DOCX 86.09 KB)
Open DOCX file, 84.18 KB,
PN Tier 2 Template: Instructions for LT2ESWTR Unfiltered System Failure to Install Second Disinfection Notice (2-17)
(English, DOCX 84.18 KB)
Open DOCX file, 99.82 KB,
PN Tier 2 Template: DBPR TTHM and HAA5 MCL Violation - Instructions and PN (2-19)
(English, DOCX 99.82 KB)
Open DOCX file, 95.23 KB,
PN Tier 2 Template: Stage 2 DBPR HAA5 MCL Violation (2-19.1)
(English, DOCX 95.23 KB)
Open DOCX file, 94.21 KB,
PN Tier 2 Template: Stage 2 DBPR TTHM MCL Violation (2-19.2)
(English, DOCX 94.21 KB)
Open DOCX file, 84.99 KB,
PN Tier 2 Template: Instructions for Filter Backwash Recycling Rule Treatment Technique Violation Notice (2-20)
(English, DOCX 84.99 KB)
Open DOCX file, 86.46 KB,
PN Tier 2 Template: Instructions for GWR Failure to Take Corrective Action within Required Time Frame Notice (2-21)
(English, DOCX 86.46 KB)
Open DOCX file, 85.81 KB,
PN Tier 2 Template: Instructions for GWR Failure to Maintain 4-log Treatment of Viruses Notice (2-22)
(English, DOCX 85.81 KB)
Open DOCX file, 85.54 KB,
PN Tier 2 Template: Instructions for Failure to Comply with the Conditions of an Exemption Notice (2-23)
(English, DOCX 85.54 KB)
Open DOCX file, 84.77 KB,
PN Tier 2 Template: Instructions for Monitoring Violation Elevated to Tier 2 Notice (2-24)
(English, DOCX 84.77 KB)
Open DOCX file, 109.35 KB,
PN Tier 2 Template: PFAS6 above the 20 ng/L MCL (2-25)
(English, DOCX 109.35 KB)
Tier 3 Templates
Templates for Non-Community Public Water Systems
Open DOC file, 107.5 KB,
Public Notification Templates for Non-Community Public Water Systems
(English, DOC 107.5 KB)
Templates for Water Treatment
Templates for Manganese
Open DOCX file, 38.83 KB,
PN Template for manganese levels between 0.30-1.0 for Community PWS
(English, DOCX 38.83 KB)
Open DOCX file, 61.01 KB,
PN Template for manganese levels greater than 1.0 for Community PWS
(English, DOCX 61.01 KB)
Public Education Templates
Open DOCX file, 69.64 KB,
Cyanotoxins Public Notice Template for Infants and Pre-school Age Children
(English, DOCX 69.64 KB)
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