Annual Water Quality Report Certification Form printable pdf download

New York State Department of Health

Annual Water Quality Report Certification Form

For the Year ______

A. Water System and Responsible Party

Community Water System Name:_____________________________________ PWS ID #:____________

Community Water System Address:___________________________________

________________________________________________________________

The community water system named above hereby confirms that its Annual Water Quality Report has been

distributed to customers (and appropriate notices of availability have been given). Further, the system

certifies that the information contained in the report is correct and consistent with the compliance

monitoring data previously submitted to the health department.

Date(s) Distributed:__________________

Certified by:

Name:______________________________

(Owner or designated operator only)

Title:_______________________________

Phone #:_____________________________

Signature:__________________________

Date:_______________________________

B. Distribution Methods

Please indicate how your report was distributed to your customers:

____ Annual Water Quality Report was distributed to bill-paying customers by mail.

____ Annual Water Quality Report was distributed to bill-paying customers by direct delivery

(please specify the direct delivery method used).

___ Hand delivered.

___ Published in local paper (e.g., Penny Saver) that was directly delivered or mailed to all

bill-paying customers.

___ Published in local municipal newsletter that was directly delivered or mailed.

___ Other (please specify) __________________________________________________.

____ System does not have bill-paying customers.

For systems serving at least 100,000 persons, in addition to distributing your report using the methods

described above, your Annual Water Quality Report must also be posted on the Internet.

____ Annual Water Quality Report is posted on the Internet at ________________________. (URL)

C. Purchase and Seller Water Supplies

For consecutive systems, please indicate how source water data was distributed:

___ Within Annual Water Quality Report

___ Attached as separate document

For systems that supply water to other public water systems, please indicate date that Annual Water Quality

Report was distributed to purchase systems:____________________

D. Non-Bill Paying Customers

Please indicate what “Good Faith” efforts were used to reach non-bill paying consumers. Those efforts

included the following methods as recommended by the New York State Department of Health.

____ Posting the Annual Water Quality Report on the Internet at ________________________. (URL)

____ Mailing the Annual Water Quality Report to postal patrons with the service area.

____ Advertising the availability of the Annual Water Quality Report in the news media.

____ Publication of the Annual Water Quality Report in a local newspaper.

____ Posting of the Annual Water Quality Report in public places (attach a list of locations).

____ Delivery of multiple copies to single-bill addresses serving several persons such as:

apartments, businesses, and large private employers.

____ Delivery to community organizations.

DOH-AWQRcert (2012-03-12 DC version)

Annual Water Quality Report Certification Form

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