"Public Water System Annual Statement" - Connecticut

Public Water System Annual Statement is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

Form Details:

  • Released on April 30, 2013;
  • The latest edition currently provided by the Connecticut State Department of Public Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Public Health.

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Download "Public Water System Annual Statement" - Connecticut

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PUBLIC WATER SYSTEM ANNUAL STATEMENT
1. Public Water System Information:
PWS ID:
PWS Name:
PWS Classification:
Population Served:
2. Contact Information:
On File
Corrected
* Salutation
* First Name
* Last Name
Organization
Job Title
* Address Line One
Address Line Two
* Town/City
* State
* Zip Code
* Business Phone (Ext)
(
)
(
)
* Emergency Phone
Mobile Phone
Fax
* Business E-mail
* indicates required information
3. Consumer Connections and Service Area Information:
Service Connection Type
Number of Connections
Key: Service Connection Type: RS – Residential; CM – Commercial;
CB – Combined; AG – Agricultural; IN - Industrial
Town(s) Served:
4. Source(s) of Supply:
Source Name
Source Type
Source Status
Key: Source Type: GW – Ground Water; SW – Surface Water; GU – GW Under the Direct Influence of SW
Source Status: A – Active; I – Inactive; P – Proposed
I certify this information to be correct:
Signature
Title
Print Name
Date
Return completed form to:
DWDCompliance@ct.gov
or
Connecticut Department of Public Health
Drinking Water Section
410 Capitol Avenue, MS #51WAT
P.O. Box 340308
Hartford, CT 06134-0308
DWS-Annual-Statement
Page 1 of 1
Rev. 4/30/2013
PUBLIC WATER SYSTEM ANNUAL STATEMENT
1. Public Water System Information:
PWS ID:
PWS Name:
PWS Classification:
Population Served:
2. Contact Information:
On File
Corrected
* Salutation
* First Name
* Last Name
Organization
Job Title
* Address Line One
Address Line Two
* Town/City
* State
* Zip Code
* Business Phone (Ext)
(
)
(
)
* Emergency Phone
Mobile Phone
Fax
* Business E-mail
* indicates required information
3. Consumer Connections and Service Area Information:
Service Connection Type
Number of Connections
Key: Service Connection Type: RS – Residential; CM – Commercial;
CB – Combined; AG – Agricultural; IN - Industrial
Town(s) Served:
4. Source(s) of Supply:
Source Name
Source Type
Source Status
Key: Source Type: GW – Ground Water; SW – Surface Water; GU – GW Under the Direct Influence of SW
Source Status: A – Active; I – Inactive; P – Proposed
I certify this information to be correct:
Signature
Title
Print Name
Date
Return completed form to:
DWDCompliance@ct.gov
or
Connecticut Department of Public Health
Drinking Water Section
410 Capitol Avenue, MS #51WAT
P.O. Box 340308
Hartford, CT 06134-0308
DWS-Annual-Statement
Page 1 of 1
Rev. 4/30/2013