Safe Drinking Water Program  

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Safe Drinking Water Program: Services and Organization

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Many documents on this site are PDF files, which require the use of the free Adobe Acrobat Reader. 

Public Water System Reporting Forms and Templates

• Safe Drinking Water Information System (SDWIS) Inventory update form  Word  PDF
• Annual Fee Inventory Update Form   Word  PDF
• Public water system self-evaluation form
• Unregulated contaminant monitoring list
• Laboratory report forms

Monitoring Plan Templates

For assistance with completing a monitoring plan, please refer to the example document below.  The example used is for a community ground water monitoring plan, the instructions are applicable to all monitoring plans.

Monitoring plan example

The following Word and PDF templates may be downloaded, saved to your computer, and populated with your site specific information.  PDF documents require the use of the free Adobe Acrobat Reader.  Should you experience difficulty downloading these forms, please be sure you have the most recent version of the free Adobe Reader.

• Monitoring Plan Master Template - Inventory Section Only
  PDF       Word
• Monitoring Plan Master Template - Rule Sampling Plans Only
  PDF       Word
• Monitoring Plan Template for Community Groundwater Systems
  PDF       Word
• Monitoring Plan Template for Community Surface Water and GWUDI Systems
  PDF       Word
• Monitoring Plan Template for Non-Transient Non-Community Groundwater Systems
  PDF       Word
• Monitoring Plan Template for Non-Transient Non-Community Surface Water and GWUDI Systems
  PDF       Word
• Monitoring Plan Template for Transient Non-Community Groundwater Systems
  PDF       Word
• Monitoring Plan Template for Transient Non-Community Surface Water and GWUDI Systems
  PDF       Word
• Monitoring Plan Template for Water Haulers
  PDF       Word
• Monitoring Plan Template for Community or Non-Transient Non Community Purchase Systems
  PDF      Word
• Monitoring Plan Template for Transient Non-Community Purchase Systems
   PDF       Word

• Monitoring Plan Template for Community Purchased Approved Integration Agreement            PDF       Word

Consumer Confidence Report

• Consumer confidence reports rule guidance handbook 
• CCR frequently asked questions (FAQ)
• CCR template  Word  PDF
• CCR Certificate of Delivery   Word   PDF

• Source Water Assessment and Protection Summary Guidance 

• Compliance Assurance and Data Management Section Contact List 

 Disinfectant and Disinfection Byproducts Rule

• D/DBP request for reduced monitoring form
• Violation notification report form (for reporting violation of the DDBP Rule)
• Stage 2 D/DBPR Initial Distribution System Evaluation Report templates
  • Initial distribution system evaluation report for standard monitoring (Excel)
  • Initial distribution system evaluation report for system specific study - modeling 
    Word     PDF
  • Initial distribution system evaluation report for system specific study - existing data
    Word      PDF

Disinfection By-Product Reporting Forms

• DBP form 3 - TTHM and HAA5 quarterly report worksheet
• DBP form 4  - Running annual average reporting form
• DBP form 6 - Quarterly reporting form for running annual average for bromate
• DBP form 7  - Quarterly report for daily, monthly and additional chlorite monitoring

 Maximum Residual Disinfectant Level Reporting Forms

Please note MRDL form 2 is no longer accepted by the division.  Water systems are required to monitor the chlorine residual with each total coliform sample and report the chlorine residual to the lab.

• MRDL Form 3  - Quarterly Report for Daily and Monthly Chlorine Dioxide

 Disinfection Byproduct Precursors Reporting Forms

• DDBP precursor form 2  - Alternative compliance criteria for enhanced coagulation treatment plants
• DDBP precursor form 3  - Alternative compliance criteria for enhanced softening treatment plants
• DDBP precursor form 4 - Actual removal ratios for enhanced coagulation and softening treatment plants

Groundwater Rule

• 4 Log Inactivation of Viruses Certification Form 
• Groundwater Entry Point Chlorine Residual Disinfectant Monitoring Log Word version

 Lead and Copper Monitoring Reporting Forms

• Sample results and collection certification form
• Materials survey form for community water system
• Materials survey form for non-transient, non-community water system
• Sample site change form
• Water quality parameters report form
• Sampling pool for lead and copper tap water samples
• Homeowner certification and instruction

 Organic Chemical Contaminants

• Glyphosate monitoring waiver request form

 Public Notification Rule

• Public notification guidance March 2003
• Public notice 10 required elements
• Translated phrases
• Waiver of disinfection certificate
• Tier 1 Required Forms
  • Tier 1 Certificate of Delivery Form
  • Tier 1 Instructions
  • Tier 1 Templates
    • Boil water advisory for E. coli or fecal bacteria
    • Boil water advisory for E. coli or fecal bacteria in Spanish
    • Boil water advisory for waterborne disease outbreak
    • Bottled water advisory
    • Bottled water advisory in Spanish
    • Chlorine dioxide MRDL violation in distribution system
    • Delayed repeats after E. coli or fecal positive sample
    • Loss of pressure boil water advisory
    • Loss of pressure bottled water advisory
    • Nitrate MCL bottled water advisory
    • Nitrate MCL bottled water advisory in Spanish
    • Tampering or security breech notice
    • Turbidity MCL public notice advisory for conventional, direct, or membrane filtration plants
    • Turbidity MCL public notice advisory for slow sand, diatomaceous earth, bag, or cartridge filtration plants
    • Unapproved source boil water advisory
• Tier 2 Required Forms
  • Tier 2 Certificate of Delivery Form
  • Tier 2 Instructions
  • Tier 2 Templates
    • Arsenic MCL violation
    • Bromate MCL violation
    • Disinfectant residual below minimum in a monthly occurrence
    • Disinfectant residual below minimum in a single occurrence
    • Failure to filter surface water (SW) or ground water under direct influence (GWUDI)
    • Failure to install corrosion control after exceeding lead action level
    • Failure to provide disinfectant contact time
    • Fluoride MCL violation
    • Haloacetic acids MCL violation
    • Other MCL violation
    • Radionuclide MCL violation
    • Total organic carbon treatment technique using alternative compliance criteria
    • Total organic carbon treatment technique using removal ratio
    • Total coliform MCL violation with no E. coli or fecal bacteria
    • Total trihalomethanes MCL violation
    • TTHM HAA5 MCL violation
    • Turbidity 95% and CI2 single occurrence violation for slow sand, DE, bag, cartridge filtration plants
    • Turbidity 95% violation for conventional, direct, or membrane filtration plants
    • Turbidity 95% violation for slow sand, diatomaceous earth, bag, or cartridge filtration plants
• Tier 3 Required Forms
  • Tier 3 Certificate of Delivery Form
  • Tier 3 Instructions
  • Tier 3 Templates
    • Monitoring and Reporting Violation
    • Fluoride Secondary MCL Exceedence
    • Total coliform failure to collect repeat samples
• Problems Corrected Notice
  • Instructions for problem corrected notice 
  • Problem corrected notice template

 Surface Water Treatment Rules Reporting Forms

• Monthly Operating Reports (MOR)

For turbidity and entry point disinfectant reporting download the instructions and the form for the filtration type used by your water treatment plant.

• New Form Instructions  
• Conventional and Direct Filtration Form
• Membrane Filtration Form
• Slow Sand, Diatomaceous Earth and Other Filtration Form

• Long term 2 enhanced surface water treatment rule templates
  • Bin Classification Report Form  
  • Intent to grandfather
  • Intent to provide maximum treatment

 Total Coliform Bacteria

• Positive total coliform investigation template

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