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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 
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 DOCX file, 364.86 KB,  PN Tier 1 Template: Coliform Rule (English, DOCX 364.86 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)
Open DOCX file, 39.81 KB,  PN Tier 1 Template: Lead Action Level Exceedance (Short Version) (English, DOCX 39.81 KB)

Open DOCX file, 25.53 KB,  PN Tier 1 Template: Lead Action Level Exceedance (Long Version) (English, DOCX 25.53 KB)

Open DOCX file, 105.39 KB,  PN Tier 1 Template: Lead Action Level Exceedance (English, DOCX 105.39 KB)

Tier 2 Templates

Open DOCX file, 84.83 KB,  PN Tier 2 Template: RTCR Failure of a Seasonal System to Complete Start-Up Procedures (2-1) (English, DOCX 84.83 KB)

Open DOCX file, 97.03 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 97.03 KB)

Open DOCX file, 100.59 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 100.59 KB)

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

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

Open DOCX file, 76.17 KB,  PN Tier 2 Template: Instructions SWTR Failure to Filter Notice (2-5) (English, DOCX 76.17 KB)

Open DOCX file, 76.31 KB,  PN Tier 2 Template: SWTR Turbidity Exceedance Notice (2-6) (English, DOCX 76.31 KB)

Open DOCX file, 75.97 KB,  PN Tier 2 Template: SWTR Disinfection Treatment Notice (2-7) (English, DOCX 75.97 KB)

Open DOCX file, 74.66 KB,  PN Tier 2 Template: LCR Failure to Install/Maintain Corrosion Control (2-8) (English, DOCX 74.66 KB)

Open DOCX file, 77.2 KB,  PN Tier 2 Template: LT2ESWTR Uncovered Finished Water Reservoir Treatment Notice (2-9) (English, DOCX 77.2 KB)

Open DOCX file, 74.42 KB,  PN Tier 2 Template: LT2ESWTR Failure to Conduct Required Cryptosporidium Monitoring for Any Three Months Notice (2-10) (English, DOCX 74.42 KB)

Open DOCX file, 76.11 KB,  PN Tier 2 Template: LT2ESWTR Filtered System Failure to Determine and Report Bin Classification Notice (2-11) (English, DOCX 76.11 KB)

Open DOCX file, 76.27 KB,  PN Tier 2 Template: LT2ESWTR Unfiltered System Failure to Calculate and Report Mean Cryptosporidium Level Notice (2-12) (English, DOCX 76.27 KB)

Open DOCX file, 119.06 KB,  PN Tier 2 Template: LT2ESWTR Filtered System Failure to Provide or Install an Additional Level of Treatment Notice (2-13) (English, DOCX 119.06 KB)

Open DOCX file, 119.5 KB,  PN Tier 2 Template: LT2ESWTR Unfiltered System Failure to Achieve Required Inactivation Level Notice (2-14) (English, DOCX 119.5 KB)

Open DOCX file, 119.51 KB,  PN Tier 2 Template: Instructions for LT2ESWTR Filtered System Failure to Achieve Required Treatment Credit Notice (2-15) (English, DOCX 119.51 KB)

Open DOCX file, 119.62 KB,  PN Tier 2 Template: Instructions for LT2ESWTR Unfiltered System Failure to Maintain Required Inactivation Level Notice (2-16) (English, DOCX 119.62 KB)

Open DOCX file, 118.99 KB,  PN Tier 2 Template: Instructions for LT2ESWTR Unfiltered System Failure to Install Second Disinfection Notice (2-17) (English, DOCX 118.99 KB)

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

Open DOCX file, 130.06 KB,  PN Tier 2 Template: Stage 2 DBPR HAA5 MCL Violation (2-19.1) (English, DOCX 130.06 KB)

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

Open DOCX file, 119.81 KB,  PN Tier 2 Template: Instructions for Filter Backwash Recycling Rule Treatment Technique Violation Notice (2-20) (English, DOCX 119.81 KB)

Open DOCX file, 121.31 KB,  PN Tier 2 Template: Instructions for GWR Failure to Take Corrective Action within Required Time Frame Notice (2-21) (English, DOCX 121.31 KB)

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

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

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

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

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

Open DOCX file, 125.45 KB,  PN Tier 2 Template: LCR Failure to Remove the Required Number of LSLs (2-27) (English, DOCX 125.45 KB)

Tier 3 Templates

Open DOC file, 48 KB,  Public Notification Template for Tier 3 Violations of Drinking Water Regulations (English, DOC 48 KB)
Open DOCX file, 69.59 KB,  Public Notice Tier 3 Template: Special Notice for Availability of UCMR Data (English, DOCX 69.59 KB)

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

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

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

Public Education Templates

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

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

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

Guidance and Factsheets to Include with Public Notices

Open DOCX file, 33 KB,  List of Affected Areas - MassDEP DWP Boil Order Template (English, DOCX 33 KB)
Open PDF file, 213.49 KB,  MassDEP DWP Factsheet - Guidance for Restaurant Establishments During a Boil Order (English, PDF 213.49 KB)
Open PDF file, 244.79 KB,  MassDEP DWP Fact Sheet: Tips for Restaurant Establishments Handwashing During a Boil Order (English, PDF 244.79 KB)
Open PDF file, 258.03 KB,  MassDEP DWP Factsheet - Drinking Water Contaminated with Bacteria (English, PDF 258.03 KB)

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