"Bulk Water Hauling Notification Form" - Connecticut

Bulk Water Hauling Notification Form 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 August 12, 2015;
  • 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 "Bulk Water Hauling Notification Form" - Connecticut

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STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
DRINKING WATER SECTION
BULK WATER HAULING NOTIFICATION FORM
This notification form should be completed and submitted to the Department after a Public Water
System (PWS) hauls in bulk water. Note that if bulk water hauling is required due to an emergency as
defined in the Section 19-13-B46 of the Regulations of Connecticut State Agencies, a Notification Form
to Confirm Compliance with Sections 19-13-B46 & 19-13-B102 of the Regulations of Connecticut State
Agencies (RCSA) must be completed and submitted.
Name of PWS receiving bulk water:
PWSID of PWS receiving bulk water: CT
Date of bulk water delivery:
Approximate quantity of bulk water delivered (gallons):
Reason(s) for bulk water delivery (be specific):
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Name of bulk water hauler:
Bulk Water Hauling License No.:
Tanker Identification Number (VIN):
Tanker License Plate No.:
Address of bulk water hauler:
Phone number of bulk water hauler:
Source of supply for bulk water (PWSID and name of regulated PWS):
Were the Bulk Water Hauling Guidelines adhered to?
Yes
No
_________________________________________________________________________________________
Signature of Receiving PWS Administrative Official, His/Her Designated Representative, or Certified Operator
Print Name: ____________________________________________________________________________
Title:
____________________________________________________________________________
Date Signed: ______________________ Telephone #: __________________________________________
Rev. 8/12/15
1 of 1
STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
DRINKING WATER SECTION
BULK WATER HAULING NOTIFICATION FORM
This notification form should be completed and submitted to the Department after a Public Water
System (PWS) hauls in bulk water. Note that if bulk water hauling is required due to an emergency as
defined in the Section 19-13-B46 of the Regulations of Connecticut State Agencies, a Notification Form
to Confirm Compliance with Sections 19-13-B46 & 19-13-B102 of the Regulations of Connecticut State
Agencies (RCSA) must be completed and submitted.
Name of PWS receiving bulk water:
PWSID of PWS receiving bulk water: CT
Date of bulk water delivery:
Approximate quantity of bulk water delivered (gallons):
Reason(s) for bulk water delivery (be specific):
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Name of bulk water hauler:
Bulk Water Hauling License No.:
Tanker Identification Number (VIN):
Tanker License Plate No.:
Address of bulk water hauler:
Phone number of bulk water hauler:
Source of supply for bulk water (PWSID and name of regulated PWS):
Were the Bulk Water Hauling Guidelines adhered to?
Yes
No
_________________________________________________________________________________________
Signature of Receiving PWS Administrative Official, His/Her Designated Representative, or Certified Operator
Print Name: ____________________________________________________________________________
Title:
____________________________________________________________________________
Date Signed: ______________________ Telephone #: __________________________________________
Rev. 8/12/15
1 of 1