Instructions for Form MO780-1231, 1 "Inventory Public Water System Record" - Missouri

This document contains official instructions for Form MO780-1231, and Form 1. Both forms are released and collected by the Missouri Department of Natural Resources. An up-to-date fillable Form MO780-1231 (1) is available for download through this link.

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Public Water System Record - Form #1
Application Instructions for Form 780-1231
11/2012
Water Protection Program fact sheet
Purpose
This form is used to record basic descriptive information about a public water system.
New Water System
To be provided by regional office staff at the time a new water system is identified.
Most of the information is required for new systems.
Information about other government agencies involved, seasonal operation and operating
permit are only required when applicable.
Existing Water System
To be provided when new construction, treatment modifications, or operational changes
occur.
Only the transaction type (upper right corner), public water system ID # and the specific
items to be changed are required. Everything else should be left blank.
Note: For all source information (category, type, percent type), the information provided
must match the other source information and inventory form #3 (MO 780-1233). If any of this
information changes, a new form #3 must be completed.
Directions
For the purpose of this form:
“Required” means data must be supplied for that field.
“Optional” means data is not necessarily required for that field unless the information
changed or is new.
Front Side of Form
Status
“New PWS” should be selected when a new water system is being identified for the first
time.
“Reactivate PWS” should be selected when a system has been deactivated and is once
again becoming a regulated system.
“Change PWS” should be selected when a system’s information changes; this includes,
but is not limited to, the system’s name, activity status, system type, seasonal dates, or any
information on the back of the form.
“Proposed PWS” is for placing a new facility into the inventory system while it is still in the
permitting stage.
PUB2434
Public Water System Record - Form #1
Application Instructions for Form 780-1231
11/2012
Water Protection Program fact sheet
Purpose
This form is used to record basic descriptive information about a public water system.
New Water System
To be provided by regional office staff at the time a new water system is identified.
Most of the information is required for new systems.
Information about other government agencies involved, seasonal operation and operating
permit are only required when applicable.
Existing Water System
To be provided when new construction, treatment modifications, or operational changes
occur.
Only the transaction type (upper right corner), public water system ID # and the specific
items to be changed are required. Everything else should be left blank.
Note: For all source information (category, type, percent type), the information provided
must match the other source information and inventory form #3 (MO 780-1233). If any of this
information changes, a new form #3 must be completed.
Directions
For the purpose of this form:
“Required” means data must be supplied for that field.
“Optional” means data is not necessarily required for that field unless the information
changed or is new.
Front Side of Form
Status
“New PWS” should be selected when a new water system is being identified for the first
time.
“Reactivate PWS” should be selected when a system has been deactivated and is once
again becoming a regulated system.
“Change PWS” should be selected when a system’s information changes; this includes,
but is not limited to, the system’s name, activity status, system type, seasonal dates, or any
information on the back of the form.
“Proposed PWS” is for placing a new facility into the inventory system while it is still in the
permitting stage.
PUB2434
PWS ID#
Identify the public water supply ID# for the water system. Leave this field blank for a new system.
PWS Name
Identify the official name of the water system or company.
County
List the primary county in which the water system is located.
PWS Website
List the system’s website (if applicable).
Dates and Certification
Required for all new systems or for deactivating a system. Indicates whether the water system
is being activated or deactivated and corresponding action date.
Season Begin/End
Required for noncommunity systems and systems operating seasonally.
Enter the first day and month of operation and the last day and month of operation.
If dates are not given, a default of Jan 31-Dec. 31 will be used.
If default is used, the system will be considered a year-round provider and it will be subject
to all the monitoring requirements of a year-round supply.
If a system is open for even one day during a given month, the system is required to monitor
for that month.
Date System Began
Required for all new systems. The month, day and year a water system started operation.
Operating Permit
If a water system has a permit to dispense, then the date the permit was issued is required.
If no permit, provide system with application for permit and leave this field blank.
Treatment and Distribution Certification Levels
Required for all new systems. Use to designate the minimum level of certification required for
the chief operator of a water system. Use “X” when certification is not required.
Ownership Type
Required for all new systems. Use to identify whether the facility is government-owned or
privately owned.
Percent Source Type
Required for all new systems. Percent of water from one or more source types must total 100
percent. Best estimate if unknown.
Facility Type
Required for all new systems. At least one service area type must be given. If more than one
service area type is given, one type must be identified as the primary type.
Note: The service area code should match the facility type code and ownership type.
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PWS Type
Required for all new systems. Identifies a system as either a community (i.e. permanent
residential community), nontransient noncommunity (i.e. nonresidential facility regularly serving
at least 25 of the same people over six months per year), or transient noncommunity (i.e.
serving a transient population).
Source Category
Required for all new systems. Classifies a water system as primary (having its own source),
secondary (purchasing all of its water from another water system), or both (having its own
source and purchasing water from another system).
Average Daily Consumption, or ADC, Within Own System
Required for community systems and optional for noncommunity systems. The average
daily amount of water used by a water system within its own immediate system (not to
include secondary customers). If the average daily consumption changes, the maximum daily
consumption must also be updated.
Maximum Daily Consumption, or MDC, Within Own System
Required for community systems and optional for noncommunity systems. The maximum
daily amount of water used by the water system within its own immediate system (not to
include secondary customers). If the maximum daily consumption changes, the average daily
consumption must also be updated.
MDC - Secondary Customers
The maximum daily amount of water the water system provides to its secondary customers.
ADC - Secondary Customers
The average daily amount of water the water system provides to its secondary customers.
Service Connections
Required for all new systems. Record the number of connections (i.e. houses, trailers, meters,
etc.) served by the water system (not to include secondary customers).
Retail Population Served
Required for all new systems.
Average daily population served by the water system (not to include secondary customers).
Other Government Agency
If a facility is owned or regulated by another government agency, that agency must be identified.
Service Area
Required for all new systems. Classifies the water system as a city, water district, subdivision,
industry, school, hotel, etc.
Total Design Capacity
The water system’s capacity for providing water.
Average Daily Production
The water system’s average daily production for all sources.
Emergency Production
The water system’s capacity for providing water in an emergency.
Total Finished Storage
The water system’s amount of water storage.
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Source Type
Required for all new systems. Use to identify one major (M) source type. Additional (A) source
types can also be indicated.
Address
Required for all new systems. This is the system address. List the location address and
telephone number for the water system. Do not use a post office box number; this must be a
street number, rural route, etc.
Completed By
Required - name of the regional office staff person completing the form.
Date
Required - date the form is completed.
Back Side of Form
PWS ID#
Identify the PWS ID# for the water system. Leave this field blank for a new system.
Geographic Area(s) Served Section
This section is used to identify the area covered by the water system. A geographic area is
defined as the county the facility lies within, and the name of the community or area served by
the water system. In the case of a water district serving three towns, the county and the three
geographic areas must be identified. A minimum of one county and one geographic area is
required for all new systems.
County - Required for all new systems. Indicate the 3-digit FIPS code for the county
where the facility or its major service area is located.
City/Area Served - Required for all new systems. List the name of the city, subdivision,
school, etc. In many cases, the name will be the same as the official water system’s name.
This is the place to list the names of the communities served by a water district or a private
water company.
Bacteriological Lab ID No. - (Optional) The identification number for the laboratory that will
analyze a system’s monthly bacteriological samples.
If a facility chooses to use the services of a private certified lab, write the name of the lab
in this space; the department will check the ID No. and certification of the lab.
If a lab is not listed, the department will assign a state health lab based on the
facility’s location.
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Site Sampling Point(s) Section
Required for all new systems. Each facility must have at least one point identified where the
monthly bacteriological samples will be collected.
Use this form to add new site sampling points to existing facilities as well as new facilities.
The site sampling points identify the locations where routine samples are collected.
If repeat samples are necessary, they will be tied to the appropriate routine sample point
using upstream, downstream and original tags.
Repeat sample sites do not need individual IDs.
Sample Location ID - Required for all new systems. Provide ID for existing sample
locations (i.e., to deactivate). For new sample locations, enter “NEW” or “99999”.
Sample Location - Required for all new systems.
Give a description of the location where the monthly bacteriological samples are to
be collected (e.g., street address, kitchen faucet, etc.)
If a facility chooses to use a residence as a sample location point, a street address
(i.e., 204 Example St.) should be given rather than the resident’s name. This will
eliminate the need for updating that location should the resident change.
A sample location point can never be deleted from the system or assigned a new
sample location ID. Should a facility change the location where they take their
samples, a new sample location point and sample location ID need to be designated
for that new sample location.
Status - Mark if the sample location is new (activate) or should be deactivated
Notes - (Optional) Use this box to give any special or additional information including
changes to required sampling (i.e., changes in the number of required TCR samples per
month).
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