"Consumer Confidence Report Certification Form" - Massachusetts

Consumer Confidence Report Certification Form is a legal document that was released by the Massachusetts Department of Environmental Protection - a government authority operating within Massachusetts.

Form Details:

  • Released on January 1, 2018;
  • The latest edition currently provided by the Massachusetts Department of Environmental Protection;
  • 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 printable version of the form by clicking the link below or browse more documents and templates provided by the Massachusetts Department of Environmental Protection.

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Download "Consumer Confidence Report Certification Form" - Massachusetts

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Massachusetts Department of Environmental Protection
Bureau of Resource Protection – Drinking Water Program
Consumer Confidence Report Certification
For calendar year
A. PWS Information
PWS Name
PWS ID
City /Town
Max population
The community water system named above
hereby certifies that its Consumer Confidence
Name
Report (CCR) was distributed to customers,
appropriate agencies, and notices of availability
Title
have been given in compliance with 310 CMR
22.16A. Furthermore, the system certifies that
Phone
the information contained in the report is correct
and consistent with the compliance monitoring
E-Mail
data previously submitted to MassDEP.
I certify under penalty of law that I am the person
Date
authorized to fill out this form and the information
contained herein is true, accurate, and complete to
Signature of Owner/Responsible Party or Certified Operator
the best of my knowledge and belief.
B. Public Notice Certification
VSS PWS note: if
Is this system using this CCR to provide Tier 3 Public Notice to their customers?
Yes
No
you deliver your
CCR by newspaper
or postings, that
The PN is for a: Violation
UCMR
Other
method will not
List other
meet PN
Did you have a consultation with MassDEP ?
Yes
No
requirements. You
Consultation date
must directly deliver
your PN by hand,
The PN can be found on page
of the CCR.
land, or electronic.
Date of PN Occurrence
NON Number
I am reporting multiple Tier 3 PNs. I have listed the additional PN information at the end of this form.
The public water system indicated above hereby affirms that a Tier 3 public notice has been provided
within this CCR to consumers in accordance with 310 CMR 22.16(4) including: delivery, content, format
requirements, notification deadlines, and that the public water system will meet future requirements for
notifying new billing units and new customers of the violation.
If you did not sell
C. For Systems Selling Water to Other Community Water Systems
water to another
community PWS
My system delivered the applicable information required at 310 CMR 22.16A(3), to the buying
skip Section C.
system(s) no later than April 1st of this year, or by the mutually agreed upon date specifically included in
a written contract between the parties.
D. Annual Cross Connection Education
Is this CCR being used for your system’s annual cross-connection education?
Yes
No
If no, what methods did you use to meet your annual CCCP requirements (citation)?
Rev 2018-01
Page 1 of 3
Massachusetts Department of Environmental Protection
Bureau of Resource Protection – Drinking Water Program
Consumer Confidence Report Certification
For calendar year
A. PWS Information
PWS Name
PWS ID
City /Town
Max population
The community water system named above
hereby certifies that its Consumer Confidence
Name
Report (CCR) was distributed to customers,
appropriate agencies, and notices of availability
Title
have been given in compliance with 310 CMR
22.16A. Furthermore, the system certifies that
Phone
the information contained in the report is correct
and consistent with the compliance monitoring
E-Mail
data previously submitted to MassDEP.
I certify under penalty of law that I am the person
Date
authorized to fill out this form and the information
contained herein is true, accurate, and complete to
Signature of Owner/Responsible Party or Certified Operator
the best of my knowledge and belief.
B. Public Notice Certification
VSS PWS note: if
Is this system using this CCR to provide Tier 3 Public Notice to their customers?
Yes
No
you deliver your
CCR by newspaper
or postings, that
The PN is for a: Violation
UCMR
Other
method will not
List other
meet PN
Did you have a consultation with MassDEP ?
Yes
No
requirements. You
Consultation date
must directly deliver
your PN by hand,
The PN can be found on page
of the CCR.
land, or electronic.
Date of PN Occurrence
NON Number
I am reporting multiple Tier 3 PNs. I have listed the additional PN information at the end of this form.
The public water system indicated above hereby affirms that a Tier 3 public notice has been provided
within this CCR to consumers in accordance with 310 CMR 22.16(4) including: delivery, content, format
requirements, notification deadlines, and that the public water system will meet future requirements for
notifying new billing units and new customers of the violation.
If you did not sell
C. For Systems Selling Water to Other Community Water Systems
water to another
community PWS
My system delivered the applicable information required at 310 CMR 22.16A(3), to the buying
skip Section C.
system(s) no later than April 1st of this year, or by the mutually agreed upon date specifically included in
a written contract between the parties.
D. Annual Cross Connection Education
Is this CCR being used for your system’s annual cross-connection education?
Yes
No
If no, what methods did you use to meet your annual CCCP requirements (citation)?
Rev 2018-01
Page 1 of 3
Continued on next page
ALL distribution
E. Consumer Delivery Methods – Based on Population Served
(posting, land
mail, or e-
For systems serving fewer than 500 persons:
delivery,
:
Date of delivery/publication
publication, and
(Choose #1 or #2)
good faith efforts)
1. My system used one or more of the following methods to notify customers that their CCR would
must be
not be mailed directly to them but is available to them upon request. (the notice is attached)
completed on or
st
before July 1
.
Land-mail
Door-to-door
Newspaper
eMail
Posted notices
Instructions for
customers to
Locations of posted notices
request a hard
copy must also
2. My system provided a CCR to each customer by the following method(s):
be included in
e-delivery.
Published the full CCR in a local newspaper (the published report from newspaper is attached).
eDelivered the CCR
Land-mailed or hand-delivered the CCR to consumers.
When a URL is
used it must be a
e-Mailed with the CCR either embedded in the email or attached as a PDF. (e-mail is attached)
direct link to the
document; no other
Posted the CCR on the web and sent the direct URL to customers by way of land-mail or email
clicks allowed.
(notice/postcard is attached).
List URL
For systems serving 500 to 9,999 persons:
Date of delivery/publication:
(Choose either #1 or #2)
1. My system provided a copy of the CCR to each customer by:
Land-mail
e-Mail with PDF of CCR
e-Mail with embedded CCR
Sent a notice (by land or e-mail) containing a direct URL to customers (copy is attached)
List the URL if used.
2.My system provided the CCR to each customer by publishing the full report in a newspaper (a copy
of the published CCR is attached) and provided notice to consumers of this action by either:
Published a notice of this in a local newspaper
Land mailed a notice of this to consumers.
e-Mailed a notice of this to consumers.
For systems serving 10,000 or more persons:
Date of delivery/publication:
My system provided a copy of the CCR to each customer by:
Land mail
e-Mail with PDF
e-Mail with embedded CCR
Sent a notice (by land or e-mail) containing a direct URL to customers
List the URL if used.
For systems serving greater than 100,000 population: In addition to one of the delivery methods
checked above, we have posted the CCR on a publicly accessible Internet site as required.
www.
List the URL used
Rev 2018-01
Page 2 of 3
F. Good Faith Delivery Methods
(minimum of 3 is required for any sized systems)
Good Faith efforts
To reach people who drink our water but are not billed customers the following were conducted in
are in addition to
addition to the required delivery:
your primary
method of delivery.
Posted the CCR on a publicly accessible Internet site at the following address. (Only for systems
under 100,000 population who did not use this method as their primary method)
www.
List the URL used.
Mailed the CCR to all postal patrons within the service area (list of zip codes used is attached).
Mailed a postcard listing the URL where the CCR can be found, to all postal patrons within the
service area (list of zip codes used is attached).
www.
List the URL used.
Advertised availability of the CCR in the following news media (the announcement is attach):
Radio
Newspaper
Television / cable
Social media
Digital signboard
Published the CCR in local newspaper (attach the published CCR).
Posted the CCR in public places i.e., post office, town hall, library (list of locations is attached).
Delivered multiple CCR copies to single-bill addresses serving several persons i.e., apartments,
businesses, large private employers (list of locations is attached).
Delivered multiple CCR copies to community organizations ( list of organizations is attached.)
Posted the CCR or a notice of availability at locations within the apartment/condo complex (list of the
locations is attached).
Deliver CCR to new residents when they move in.
Other
G. Mandatory Agency Delivery Requirements
All systems must
submit CCR to
1. Local Board of Health
these three
Deliver 1 copy of CCR and the Certification Form (Contact your board of
Date completed
agencies
health as to whether they would prefer hardcopy or e-delivery of CCR.)
2. MA Dept. of Public Health
Agencies and
Deliver 1-copy of CCR and the Certification Form
Date completed
consumers must
PDF emailed to:
dph.ccr@massmail.state.ma.us
receive CCR on or
or
before July 1.
Hardcopy to: 250 Washington St.; Boston, MA 02108
3. MassDEP Boston Office
For e-delivery, scan
Deliver 1 copy of CCR, the Certification Form, and all needed attachments
Date completed
documents into 1
PDF emailed to: Program.Director-DWP@state.ma.us.
PDF file. Make sure
Cert Form is first
Label it [(PWSID)(PWS Name)(YEAR)CCR]
with CCR following
or
it.
th
Hardcopy to: MassDEP-CCR Program, 1 Winter St. -5
Fl.; Boston, MA
02108
--Do not send to MassDEP regional offices--
Only Boston is accepting CCRs
Rev 2018-01
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