Form DPH-FL-B "Massachusetts Department of Public Health Weekly Distribution System Fluoridation Report Form" - Massachusetts

What Is Form DPH-FL-B?

This is a legal form that was released by the Massachusetts Department of Environmental Protection - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 12, 2007;
  • The latest edition provided by the Massachusetts Department of Environmental Protection;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DPH-FL-B by clicking the link below or browse more documents and templates provided by the Massachusetts Department of Environmental Protection.

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Download Form DPH-FL-B "Massachusetts Department of Public Health Weekly Distribution System Fluoridation Report Form" - Massachusetts

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MASS/DEPARTMENT OF PUBLIC HEALTH
DPH-FL-B (weekly)
WEEKLY DISTRIBUTION SYSTEM FLUORIDATION REPORT Month of __________
Section I.
INSTRUCTIONS:
Each week during the month, the PWS must collect at least 1 sample from a tap(s) in its distribution system for a total of at least 4
distribution samples per month. At least one distribution sample should be collected at a location near a school. If the system is providing
water to other consecutive PWS it must evenly distribute its 4 samples across the entire combined distribution system.
Section II. PWS INFORMATION:
PWS Name:
___________________ 2. PWS ID#:
______________ 3. City/Town or District:
________________
List all contributing Fluoridated Source(s) /MassDEP Source Code/Location ID:
______________________________________
Which days
Distribution System Samples
Results
Name of Tester & Comments
of the month
e.g. reason(s) for not sampling
Collected and Analyzed with PWS Analytical
of Weekly
were
Use additional paper if necessary
Equipment.
Fluoride *
(Equipment must be acceptable to MassDEP and DPH)
distribution samples
samples
Test (ppm)
Sample
Sample Address
SPLIT SAMPLE
collected
Check ( ) if this
analyzed
Location
and
distribution
by PWS
# or name
analyzed?
sample will be
split for analysis?
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I certify under penalty of law that I am the person authorized to fill out this form and the information contained herein is true, accurate,
and complete to the best of my knowledge and belief.
Name of PWS certified operator or responsible party:
___________________ Signature: __________________ Date:
____
Phone #:
__________________Fax#:
__________________ Email address:
________________________________
Section III. DPH USE:
Date received
__________ Comments:
_______________________________________
th
PWSs approved by MassDEP for Fluoridation treatment must return all pages of this report form (A, B &C) by the 10
day following the reporting
th
month to: Department of Public Health, 250 Washington Street-5
floor, Boston, MA 02108. Attn: Office of Oral Health
DPH Fl-B 2-12-07
MASS/DEPARTMENT OF PUBLIC HEALTH
DPH-FL-B (weekly)
WEEKLY DISTRIBUTION SYSTEM FLUORIDATION REPORT Month of __________
Section I.
INSTRUCTIONS:
Each week during the month, the PWS must collect at least 1 sample from a tap(s) in its distribution system for a total of at least 4
distribution samples per month. At least one distribution sample should be collected at a location near a school. If the system is providing
water to other consecutive PWS it must evenly distribute its 4 samples across the entire combined distribution system.
Section II. PWS INFORMATION:
PWS Name:
___________________ 2. PWS ID#:
______________ 3. City/Town or District:
________________
List all contributing Fluoridated Source(s) /MassDEP Source Code/Location ID:
______________________________________
Which days
Distribution System Samples
Results
Name of Tester & Comments
of the month
e.g. reason(s) for not sampling
Collected and Analyzed with PWS Analytical
of Weekly
were
Use additional paper if necessary
Equipment.
Fluoride *
(Equipment must be acceptable to MassDEP and DPH)
distribution samples
samples
Test (ppm)
Sample
Sample Address
SPLIT SAMPLE
collected
Check ( ) if this
analyzed
Location
and
distribution
by PWS
# or name
analyzed?
sample will be
split for analysis?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
I certify under penalty of law that I am the person authorized to fill out this form and the information contained herein is true, accurate,
and complete to the best of my knowledge and belief.
Name of PWS certified operator or responsible party:
___________________ Signature: __________________ Date:
____
Phone #:
__________________Fax#:
__________________ Email address:
________________________________
Section III. DPH USE:
Date received
__________ Comments:
_______________________________________
th
PWSs approved by MassDEP for Fluoridation treatment must return all pages of this report form (A, B &C) by the 10
day following the reporting
th
month to: Department of Public Health, 250 Washington Street-5
floor, Boston, MA 02108. Attn: Office of Oral Health
DPH Fl-B 2-12-07