Public Notification Certification Form - Tiers 1, 2 & 3
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1
2
3BSDW 53
Office Use Only
10/09
Reviewed by:
Date:
Department of Environmental Protection - Bureau of Water System Engineering
401 East State Street - PO Box 420
Trenton, New Jersey 08625-0420
Tel# (609) 292-2957 – Fax# (609) 292-1654
Public Notification Certification Form – Tiers 1, 2 & 3
Requirements Pursuant to 40 CFR 141, Subpart Q and N.J.A.C. 7:10
**This form and a copy of your Notice to the Public must be submitted to the State within 10 days of notifying your customers. **
PWSID#: ____________
Water System Name: ______________
Violation #: _____
Violation or Situation Date: ________________
Individual Contaminant or Contaminant Group: _______________________
Monitoring Period: ___________________________
Violation or Situation Type: (Check appropriate box)
MCL
Treatment Technique
Water Main Break
MRDL
E. coli Positive Source Water Sample
Monitoring and Reporting
Other: _______________
Violation or Situation Public Notification Tier: (Check appropriate box)
Tier 1
Tier 2
Tier 3
Please check all that apply and provide information as indicated below:
1.
Consulted with DEP within 24 hours (Tier 1) or 48 hours (Tiers 2 & 3)
Date: __________
2.
Distributed the notice by the following method(s), and on the following date(s) in accordance with 40 CFR 141.201 et seq:
Reverse 911
Date: __________
Continuously Post
Date: __________
Separate Mailing to Customers
Date: __________
Hand Deliver Notice to Customers
Date: __________
Publish Notice in Newspaper
Date: __________
Release Notice to and Announced by Broadcast Media
Date: __________
Post Notice on System Website
Date: __________
Billing
Date: __________
Annual Report (Consumer Confidence Report)
Date: __________
Other: ________________________________
Date: __________
Note: Non-community water systems that serve a school, preschool or daycare must also hand deliver the notice to a parent or legal guardian of
each child for Tier 1, 2 and 3 violations and situations. For more information reference EPA’s Public Notification Handbook at:
3.
Content – 10 Required Elements Checklist: 40 CFR 141 Subpart Q (Ensure all items are included in the notice)
Description of violation or situation including contaminant and contaminant levels as appropriate
Date violation or situation occurred.
Potential adverse health risks, using mandatory language provided in the rule.
Required language for Monitoring and Reporting Violations, provided in the rule
The population at risk, including sub-populations particularly vulnerable if exposed.
Whether alternate water supply should be used.
What action consumers should take, including when to seek medical help, if known.
What the system is doing to correct the violation or situation.
When the system expects to return to compliance or resolve the situation.
Contact information: Owner name, business address, and phone number of the water system owner, operator or designee that
can provide additional information concerning the notice.
A statement encouraging recipients to distribute the notice to other persons served, using standard language from the rule.
4.
Attach a copy of the posted Public Notice(s) to this certification form.
The public water system named above hereby certifies that public notification has been provided to its consumers in accordance with all
delivery, content, and format requirements specified in 40 CFR Part 141 and N.J.A.C 7:10.
Owner/Operator: ____________________________________ __________________________________ ___________________
(circle one)
(Signature)
(Print Name)
(Phone Number)
Date of Certification: _______________________________
Operator License # (if applicable) ________________________
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