Form RTCR-1 "Coliform Bacteria Level 1 Assessment" - Massachusetts

What Is Form RTCR-1?

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 July 1, 2016;
  • 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 RTCR-1 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 RTCR-1 "Coliform Bacteria Level 1 Assessment" - Massachusetts

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Massachusetts Department of Environmental Protection
Bureau of Resource Protection – Drinking Water Program
RTCR-1
Coliform Bacteria Level 1 Assessment
PWS ID#:
PWS Name:
City/Town:
System Type: COM
NTNC
TNC
Compliance Period: Month
Year
Assessment Trigger Date:
Date Assessment Completed:
NOTE
Form to be completed based on data and documents available to the PWS and returned to MassDEP as soon as
:
practical but no later than 30 days after the collection date of the sample that triggered the assessment
Section A: Review and evaluate all the listed elements typically found in a PWS. Check any potential causes of
contamination identified or check “NA” if the section is not applicable to the PWS. Each section requires a response.
1. GENERAL
Issue identified: YES
NO
Have any of the following occurred prior to collecting bacteria samples?
low/inadequate disinfectant residual
pressure loss/inadequate pressure (<20 psi)*
signs of vandalism/forced entry
visible indicators of unsanitary conditions
water quality parameters out of range
power loss
system does not provide disinfection
other:
2. OPERATIONAL CHANGES
Issue identified: YES
NO
source added/removed
operation/maintenance activities
power loss
other:
3. SAMPLING SITES
Issue identified: YES
NO
unclean or unsuitable sample tap
change in conditions at sample site
hot water intrusion
unapproved/alternate site
POE/POU treatment identified
other:
4. SAMPLING PROTOCOL
Issue identified: YES
NO
improper sample container
sampler error
auto sensing faucet/swivel-type faucet
aerator was not removed
inadequate tap flushing
improper hold time/storage temperature
lab indicates possible error
change in sample collector
other:
5. TREATMENT PROCESS
Issue identified: YES
NO
NA
O & M procedures not followed
unprotected by-pass in treatment process*
inadequate disinfection
turbidity measurements out of range
filter or media contamination
change in flow rates
treatment added or changed
interruption in treatment/power loss
recent installation/repair
phosphate barrels Cl
less than 10 mg/L free chlorine residual (not applicable when the phosphate contains zinc)
other:
6. DISTRIBUTION SYSTEM
Issue identified: YES
NO
NA
low flow/dead end
main breaks
operation of isolation valves resulting in breakage
standing water/debris in valve vault
leaks
flushing of fire hydrants or blow-offs
low disinfection residuals
illegal use of hydrants
improper operation of air-relief/air-vacuum valves
known bio-film accumulation
improper surge control
installation of new mains or construction activity
unprotected cross connection*
booster pump failure
fire fighting event/flushing/sheared hydrant
improper operation of gate valves
other:
Doc Rev 7/2016
Coliform Bacteria Level 1 Assessment Form Page 1 of 3
Massachusetts Department of Environmental Protection
Bureau of Resource Protection – Drinking Water Program
RTCR-1
Coliform Bacteria Level 1 Assessment
PWS ID#:
PWS Name:
City/Town:
System Type: COM
NTNC
TNC
Compliance Period: Month
Year
Assessment Trigger Date:
Date Assessment Completed:
NOTE
Form to be completed based on data and documents available to the PWS and returned to MassDEP as soon as
:
practical but no later than 30 days after the collection date of the sample that triggered the assessment
Section A: Review and evaluate all the listed elements typically found in a PWS. Check any potential causes of
contamination identified or check “NA” if the section is not applicable to the PWS. Each section requires a response.
1. GENERAL
Issue identified: YES
NO
Have any of the following occurred prior to collecting bacteria samples?
low/inadequate disinfectant residual
pressure loss/inadequate pressure (<20 psi)*
signs of vandalism/forced entry
visible indicators of unsanitary conditions
water quality parameters out of range
power loss
system does not provide disinfection
other:
2. OPERATIONAL CHANGES
Issue identified: YES
NO
source added/removed
operation/maintenance activities
power loss
other:
3. SAMPLING SITES
Issue identified: YES
NO
unclean or unsuitable sample tap
change in conditions at sample site
hot water intrusion
unapproved/alternate site
POE/POU treatment identified
other:
4. SAMPLING PROTOCOL
Issue identified: YES
NO
improper sample container
sampler error
auto sensing faucet/swivel-type faucet
aerator was not removed
inadequate tap flushing
improper hold time/storage temperature
lab indicates possible error
change in sample collector
other:
5. TREATMENT PROCESS
Issue identified: YES
NO
NA
O & M procedures not followed
unprotected by-pass in treatment process*
inadequate disinfection
turbidity measurements out of range
filter or media contamination
change in flow rates
treatment added or changed
interruption in treatment/power loss
recent installation/repair
phosphate barrels Cl
less than 10 mg/L free chlorine residual (not applicable when the phosphate contains zinc)
other:
6. DISTRIBUTION SYSTEM
Issue identified: YES
NO
NA
low flow/dead end
main breaks
operation of isolation valves resulting in breakage
standing water/debris in valve vault
leaks
flushing of fire hydrants or blow-offs
low disinfection residuals
illegal use of hydrants
improper operation of air-relief/air-vacuum valves
known bio-film accumulation
improper surge control
installation of new mains or construction activity
unprotected cross connection*
booster pump failure
fire fighting event/flushing/sheared hydrant
improper operation of gate valves
other:
Doc Rev 7/2016
Coliform Bacteria Level 1 Assessment Form Page 1 of 3
7. STORAGE TANKS
Issue identified: YES
NO
NA
recent work on tank
evidence of contamination from animals
low disinfectant residual
presence of dead animals/insects
lack of maintenance, cleaning, or inspection
unauthorized access/signs of vandalism
hatch not sealed 
standing water/debris in control vault
Tank(s) out of service
incorrect operation of level control valves/altitude valves/related appurtenances 
water age/inadequate turnover
unaddressed inspection findings 
tank design issues (overflow, vent, hatch, screen size, etc.)
deterioration, rust, holes, or other breaches in vent, overflow pipe, access hatch, screens, ladders, etc.*
other:
8. SOURCES
Issue identified: YES
NO
NA
damaged pitless adaptor
well pit with standing water or evidence of flooding*
flooding/run-off inundation*
improper development/poorly maintained spring box
missing/damaged grout seal
defective/damaged well cap/well seal*
damaged well casing*
recent work on pump
damaged/unscreened vent*
unapproved source*
ground slopes towards well
activities in Zone I and/or Zone II
change in sources
recent heavy rainfall/snowmelt
unprotected opening in pump/pump assembly
well cap not water tight
other:
* Indicates Groundwater Rule Significant Deficiency
310 CMR 22.15(9)(b)1.d. requires the discovery of malicious intent or an act of vandalism be reported to MassDEP within two hours.
Section B - Issue Description Use this space to describe the event and provide additional information on potential
causes of contamination identified during the assessment. Include corresponding dates with your findings (attach
additional pages if needed). Include dates of sample collection, disinfection, flushing, photographs showing system
components, etc. with your findings.
Check if PWS did not find any causes for the contamination.
Section C - Corrective Action Taken or to be Taken Use this space to describe corrective actions completed, a
proposed timetable for any corrective actions not already completed, and any interim measures the PWS plans to
implement prior to the completion of any corrective actions, including specific milestone dates for doing so (attach
additional pages if needed). Include photographs showing system components. Failure to meet milestone dates is subject
to enforcement and public notice provisions.
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Coliform Bacteria Level 1 Assessment Form Page 2 of 3
Section D - Compliance History
1. Was the PWS required to complete a Level 1 Assessment in the last 12 months? Yes
No
If Yes, was the source of contamination identified? Yes
No
2. Was the PWS required by MassDEP during the last survey, inspection or other communication to address any
issue(s)? Yes
No
If yes, date issue was identified
. Were all corrective actions completed? Yes
No
If no, describe the issue and indicate your plan and a proposed timetable for any corrective actions. (attach additional
pages if needed)
NOTE: The PWS is responsible for correcting all open violations. Contact your MassDEP Regional Office for assistance
with violation and enforcement actions.
Certification: 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.
Print Name:
Title:
Signature:
Date:
Phone #:
Email:
Please return this form to your MassDEP Drinking Water Program regional office
DWP USE ONLY: MassDEP Reviewer:
Level 1 Assessment Accepted: YES
NO
PWS has corrected the problem: YES
NO
MassDEP Consultation Date if needed :
Corrective Action Plan approved: YES
NO
NA
Approved With Changes (attached)
Comments:
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