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Public Notification Forms and Templates

For Massachusetts' public drinking water systems.
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Table of Contents

Certification Forms

Public Notification Certification Form for Tier 1-3 violations (DOCX 144.39 KB)
Public Notification Certification Form for Tier 1-3 violations (PDF 189.19 KB)
Manganese Certification Form for Public Notice of a Manganese Health Advisory (DOC 62 KB)
Manganese Certification Form for Public Notice of a Manganese Health Advisory (PDF 17.26 KB)
PFAS Certification Form for Public Notice of a PFAS Health Advisory (PDF 100.86 KB)
PFAS Certification Form for Public Notice of a PFAS Health Advisory (DOCX 47.97 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 (DOC 296.5 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 19.82 KB)
PN Tier 2 Template: Stage 2 DBPR TTHM or HAA5 MCL Violation Instructions and PN (2-19) (DOCX 20.15 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)

Tier 3 Templates

Public Notification Template for Tier 3 Violations of Drinking Water Regulations (DOC 48 KB)
Public Notice Tier 3 Template: Special Notice for Availability of UCMR Data (DOC 118 KB)

Templates for Non-Community Public Water Systems

Public Notification Templates for Non-Community Public Water Systems (DOC 107.5 KB)

Templates for Water Treatment

Public Notification Template when Switching from Chlorine to Chloramines (DOCX 27.9 KB)
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