"Emergency Certification of Public Water System Temporary Closure (Non-operational Status) - for Non-community (Tnc/Ntnc) Public Water Suppliers" - Massachusetts

Emergency Certification of Public Water System Temporary Closure (Non-operational Status) - for Non-community (Tnc/Ntnc) Public Water Suppliers 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, 2020;
  • The latest edition currently provided by the Massachusetts Department of Environmental Protection;
  • Ready to use and print;
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Download a fillable 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 "Emergency Certification of Public Water System Temporary Closure (Non-operational Status) - for Non-community (Tnc/Ntnc) Public Water Suppliers" - Massachusetts

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Massachusetts Department of Environmental Protection
City/Town
Bureau of Water Resources – Drinking Water Program
Emergency Certification of Public Water System
PWS Name
Temporary Closure (Non-Operational Status)
For non-community (TNC, NTNC) public water suppliers
PWS ID #
In accordance with
Purpose
310 CMR
22.03(12), a public
water system is in
This form is for use when the Governor of Massachusetts has declared a State of Emergency* and
operation during the
a Non-Community Public Water System (PWS) has to temporarily close. Examples of state emergencies
period the system is
include COVID-19, hurricanes, and ice storms.
providing (pumping
or gravity feeding)
water to the water
This form must be completed by the non-community public water supplier to indicate the start of
distribution system
the period when it is NOT operating and regular monitoring is NOT being conducted.
and/or the public
water system is
providing water to
Please note: If a non-community public water system has already provided written documentation
at least one of its
for the closure of the PWS due to the Covid-19 declared State of Emergency to its MassDEP
service connections
regional office then it is not necessary to complete and submit this form.
or customers.
Active public water
systems must
Pl
ease note: Prior to returning to operation, the PWS must also perform start-up activities as
continue to be
listed in Section B and must complete and submit a signed copy of the modified** Seasonal Start Up
monitored and
maintained in
Procedure and Certification Form to MassDEP Drinking Water Program. Please note all start-up samples
accordance with
collected prior to re-opening the system must be free from coliform bacteria and all samples must be
310 CMR 22.00.
analyzed by a Massachusetts Certified Laboratory.
For public water
systems that are
** To modify the 'Seasonal Start Up Procedure and Certification Form' please add "COVID-19
not in operation
Closure" or other “[emergency designation] Closure” to the top of the form.
during a declared
State of
Emergency,
Return Instructions
monitoring as
specified at 310
CMR 22.00 is not
Please complete, scan, and return this form as an email attachment to
program.director-
required, unless
dwp@mass.gov
Subject: PWS Closure.
otherwise specified
by MassDEP.
A. Date Public Water System CLOSED (Became Non-Operational)
*Upon the request
of MassDEP, this
Date of closure (MM/DD/YYYY):
form may be
required for use for
other emergency
closures.
For questions
B. Certification Statement
contact your
regional Drinking
Water Program
Name of PWS or PWS representative certifying official:
contact or email
program.director-
I hereby certify that the public water system identified on this form is not/will not be operating and the
dwp@mass.gov
drinking water supplied by the public water system is not/will not be accessible for consumption in any
way. By checking off and certifying below, I attest that:
In accordance with 310 CMR 22.03(12) the public water system will not be/has not been providing
water to at least one service connection or customer as of the date of closure in Section A;
Rev 2020-04
Page 1 of 2
Massachusetts Department of Environmental Protection
City/Town
Bureau of Water Resources – Drinking Water Program
Emergency Certification of Public Water System
PWS Name
Temporary Closure (Non-Operational Status)
For non-community (TNC, NTNC) public water suppliers
PWS ID #
In accordance with
Purpose
310 CMR
22.03(12), a public
water system is in
This form is for use when the Governor of Massachusetts has declared a State of Emergency* and
operation during the
a Non-Community Public Water System (PWS) has to temporarily close. Examples of state emergencies
period the system is
include COVID-19, hurricanes, and ice storms.
providing (pumping
or gravity feeding)
water to the water
This form must be completed by the non-community public water supplier to indicate the start of
distribution system
the period when it is NOT operating and regular monitoring is NOT being conducted.
and/or the public
water system is
providing water to
Please note: If a non-community public water system has already provided written documentation
at least one of its
for the closure of the PWS due to the Covid-19 declared State of Emergency to its MassDEP
service connections
regional office then it is not necessary to complete and submit this form.
or customers.
Active public water
systems must
Pl
ease note: Prior to returning to operation, the PWS must also perform start-up activities as
continue to be
listed in Section B and must complete and submit a signed copy of the modified** Seasonal Start Up
monitored and
maintained in
Procedure and Certification Form to MassDEP Drinking Water Program. Please note all start-up samples
accordance with
collected prior to re-opening the system must be free from coliform bacteria and all samples must be
310 CMR 22.00.
analyzed by a Massachusetts Certified Laboratory.
For public water
systems that are
** To modify the 'Seasonal Start Up Procedure and Certification Form' please add "COVID-19
not in operation
Closure" or other “[emergency designation] Closure” to the top of the form.
during a declared
State of
Emergency,
Return Instructions
monitoring as
specified at 310
CMR 22.00 is not
Please complete, scan, and return this form as an email attachment to
program.director-
required, unless
dwp@mass.gov
Subject: PWS Closure.
otherwise specified
by MassDEP.
A. Date Public Water System CLOSED (Became Non-Operational)
*Upon the request
of MassDEP, this
Date of closure (MM/DD/YYYY):
form may be
required for use for
other emergency
closures.
For questions
B. Certification Statement
contact your
regional Drinking
Water Program
Name of PWS or PWS representative certifying official:
contact or email
program.director-
I hereby certify that the public water system identified on this form is not/will not be operating and the
dwp@mass.gov
drinking water supplied by the public water system is not/will not be accessible for consumption in any
way. By checking off and certifying below, I attest that:
In accordance with 310 CMR 22.03(12) the public water system will not be/has not been providing
water to at least one service connection or customer as of the date of closure in Section A;
Rev 2020-04
Page 1 of 2
Massachusetts Department of Environmental Protection
City/Town
Bureau of Water Resources – Drinking Water Program
Emergency Certification of Public Water System
PWS Name
Temporary Closure (Non-Operational Status)
For non-community (TNC, NTNC) public water suppliers
PWS ID #
A round of coliform samples in accordance with the public water system’s approved Coliform
Sampling Plan (i.e., applicable sources, entry points, distribution system) will be collected and
analyzed prior to re-opening and making the water from the public water system accessible to
any persons (other than those persons necessary to perform start-up procedures and sampling).
Any “startup” samples collected prior to re-opening to the public are considered special samples
(coded “SS”) and do not count as routine samples (coded “RS”) for the opening month. During a
state-designated State of Emergency, a public water system may contact its MassDEP regional office
to determine if a “start-up” sample will be considered for acceptance in lieu of a routine compliance
sample.
All results, including “start-up” samples collected prior to re-opening, must be reported to MassDEP
on state bacteriological report forms (Form “B") or submitted by a Massachusetts’ Certified
Laboratory via eDEP.
Start-up procedures may include flushing and/or disinfection prior to sampling due to the water being
.
stagnant for a long period of time
See
https://www.mass.gov/service-details/seasonal-start-up-information-certification-and-checklist-
for-non-community-systems
for start-up procedures questions.
A “Modified State of Emergency” Seasonal Start-up Procedure and Certification form will be
submitted to MassDEP by email no less than three (3) days prior to serving water to the public. The
form will be emailed to program.director-dwp@mass.gov, Subject: [Region] Modified Seasonal Start
Form. A copy of the form is available at
https://www.mass.gov/doc/seasonal-start-up-procedure-
certification-0/download.
If the water becomes accessible to any persons without following the sampling requirements or
notification requirements, the public water system shall be subject to all applicable violations incurred
since the date of closure indicated in Section A of this form.
C. PWS Certification -
To be completed by PWS owner, operator, or responsible party
I attest to the accuracy of the above and certify that the public water system identified on this form is NOT
operating as defined in 310 CMR 22.03(12) and will not return to “providing water to at least one of its
service connections or customers” until the required actions listed above in Section B are completed.
I certify under penalty of law that I am duly authorized to complete and submit this form on behalf of the
public water system identified above and that the information contained herein is true, accurate and
complete to the best of my knowledge and belief.
Print Name:
Title:
Signature:
Date:
Phone #:
Email:
Rev 2020-04
Page 2 of 2
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