"Ccr Certification Form (Systems Serving Less Than 10,000 Persons)" - North Dakota

Ccr Certification Form (Systems Serving Less Than 10,000 Persons) is a legal document that was released by the North Dakota Department of Environmental Quality - a government authority operating within North Dakota.

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2019 CCR Certification Form
Systems Serving less than 10,000 Persons
PWS Name:________________________________
PWS Number:___________________
The community water system hereby confirms that the Consumer Confidence Report has been
distributed to customers (or appropriate notices of availability have been given). Further, the
system certifies that the information contained in the report is correct and consistent with the
compliance monitoring data.
The following items are mandatory:
________
Published the CCR in the local newspaper(s) or mailed CCR to all
customers, or provided written notice of CCR electronic availability. (For
e-delivery, a one- click URL link must lead directly to CCR. If customer
prefers paper copy or if electronic delivery is unsuccessful, CCR must be
made available through alternate method. Reverse 911 is not allowed.)
List the dates and newspapers:
____________________________________________________________
________
If published, how informed customers the CCR will not be mailed. List
methods of notification (must be separate from published report):
____________________________________________________________
________
List the procedures to make reports available upon request. Specify:
________________________________________________________
Delivered CCR to North Dakota Department of Environmental Quality DWP.
________
Delivered CCR to local health unit and/or county health nurse. List below:
___________________________________________________________
________
A statement about the “Good Faith” effort was used in the CCR to reach
consumers who do not receive water bills.
The following two “good faith” options were also used:
________
delivered multiple copies for distribution by single-bill customers such as
apartment buildings or large private employers
________
posting the CCR on the Internet at ________________________________
________
mailed the CCR to postal patrons within the service area (attach zip codes
used)
________
advertised availability of the CCR in news media (attach a copy)
________
posting the CCR in public places or social media (attach a list of locations)
________
delivery to community organizations (attach a list)
Certified by:
Name________________________________ Title_________________________
Telephone Number_____________________ Date__________________________
This certification form must be mailed or delivered to the North Dakota Department of Environmental
Quality, Drinking Water Program, 918 E Divide Ave, Bismarck, ND 58501-1947 within three months of
notification to all customers or by October 1, 2020.
2019 CCR Certification Form
Systems Serving less than 10,000 Persons
PWS Name:________________________________
PWS Number:___________________
The community water system hereby confirms that the Consumer Confidence Report has been
distributed to customers (or appropriate notices of availability have been given). Further, the
system certifies that the information contained in the report is correct and consistent with the
compliance monitoring data.
The following items are mandatory:
________
Published the CCR in the local newspaper(s) or mailed CCR to all
customers, or provided written notice of CCR electronic availability. (For
e-delivery, a one- click URL link must lead directly to CCR. If customer
prefers paper copy or if electronic delivery is unsuccessful, CCR must be
made available through alternate method. Reverse 911 is not allowed.)
List the dates and newspapers:
____________________________________________________________
________
If published, how informed customers the CCR will not be mailed. List
methods of notification (must be separate from published report):
____________________________________________________________
________
List the procedures to make reports available upon request. Specify:
________________________________________________________
Delivered CCR to North Dakota Department of Environmental Quality DWP.
________
Delivered CCR to local health unit and/or county health nurse. List below:
___________________________________________________________
________
A statement about the “Good Faith” effort was used in the CCR to reach
consumers who do not receive water bills.
The following two “good faith” options were also used:
________
delivered multiple copies for distribution by single-bill customers such as
apartment buildings or large private employers
________
posting the CCR on the Internet at ________________________________
________
mailed the CCR to postal patrons within the service area (attach zip codes
used)
________
advertised availability of the CCR in news media (attach a copy)
________
posting the CCR in public places or social media (attach a list of locations)
________
delivery to community organizations (attach a list)
Certified by:
Name________________________________ Title_________________________
Telephone Number_____________________ Date__________________________
This certification form must be mailed or delivered to the North Dakota Department of Environmental
Quality, Drinking Water Program, 918 E Divide Ave, Bismarck, ND 58501-1947 within three months of
notification to all customers or by October 1, 2020.