"Manganese Certification Form for Public Notice of a Manganese Health Advisory" - Massachusetts

Manganese Certification Form for Public Notice of a Manganese Health Advisory is a legal document that was released by the Massachusetts Department of Environmental Protection - a government authority operating within Massachusetts.

Form Details:

  • Released on April 1, 2015;
  • 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 "Manganese Certification Form for Public Notice of a Manganese Health Advisory" - Massachusetts

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Massachusetts Department of Environmental Protection
Bureau of Water Resources – Drinking Water Program
Public Health Advisory: Manganese
Levels greater than 300 µg/L
CERTIFICATION
Make sure to send your MassDEP regional office Drinking Water Program and local board of health a
copy of each type of notice and a certification that you have met all the public notice requirements
within ten days after issuing the notice (310 CMR 22.15(3)(b)). When you certify, you are also stating
that you will meet future requirements for notifying new units of the manganese public health
advisory.
Important: When
filling out forms
PWS ID#
City/Town
on the computer,
use only the tab
Community
Non-community
PWS Name
key to move your
cursor - do not
Date(s) water level exceeded 300 µg/L for manganese:
use the return
Date
key.
The public water system indicated above hereby affirms that public notice has been provided to local
health officials and consumers in accordance with 310 CMR 22.16 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 exceedance.
Date of MassDEP notification:
Date
Notice to local health official distributed by
Method
on
Date
Name of health official
Notice to consumers distributed by
Method(s)
on
Date(s)
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.
Signature of owner or operator
Date
Printed name of owner or operator
manganex.doc • 04/2015
Public Advisory: Manganese Exceedance • Page 1 of 1
Massachusetts Department of Environmental Protection
Bureau of Water Resources – Drinking Water Program
Public Health Advisory: Manganese
Levels greater than 300 µg/L
CERTIFICATION
Make sure to send your MassDEP regional office Drinking Water Program and local board of health a
copy of each type of notice and a certification that you have met all the public notice requirements
within ten days after issuing the notice (310 CMR 22.15(3)(b)). When you certify, you are also stating
that you will meet future requirements for notifying new units of the manganese public health
advisory.
Important: When
filling out forms
PWS ID#
City/Town
on the computer,
use only the tab
Community
Non-community
PWS Name
key to move your
cursor - do not
Date(s) water level exceeded 300 µg/L for manganese:
use the return
Date
key.
The public water system indicated above hereby affirms that public notice has been provided to local
health officials and consumers in accordance with 310 CMR 22.16 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 exceedance.
Date of MassDEP notification:
Date
Notice to local health official distributed by
Method
on
Date
Name of health official
Notice to consumers distributed by
Method(s)
on
Date(s)
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.
Signature of owner or operator
Date
Printed name of owner or operator
manganex.doc • 04/2015
Public Advisory: Manganese Exceedance • Page 1 of 1