349 DEP Report 6-24-20)asstlP,�Massachusetts DepartmentProtection
Bureau of Resource Protection — Drinking Water Program
Consumer Confidence Report Certificatio-i
t S
A. PWS Information
Important:
When filling out
PWS Name GiWpA MArNOA
forms on the
computer, use
only the tab key
City frown (•eeoS
to move your
cursor =do not -- --
The community water system named above
use the return
hereby certifies that its Consumer
key.
Confidence Report (CCR) was distributed to
m
customers, appropriate agencies, and
notices of availability have been given in
compliance with 310 CMR 22.16A.
Furthermore, the system certifies that the
information contained in the report is correct
and consistent with the compliance
monitoring data previously submitted to
MaSSDEP.
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.
B. Public Notice Certification
PWS ID QIt{001
Maxpopulation `.Zn .FSTAIPl:
Name _ 3E% l'AtL-oaA--rH
Title 6e-p_Tjipi, 0 W 4,rFYL
OWAAgro2
Phone �1 t 3 21q • �q $2
E -Mail ZEq Ntl_ 4•r-1 IQYY4Noo.00 4l
Date fo22�/(/J�2OZ
Signature of Owner/Responsible Party or Certified O
aP�.AA�2
VSS PWS note: if
you deliver your Is this system using this CCR to provide Tier 3 Public Notice to their customers?
CCR by newspaper
or postings, that The PN is for a: Violation UCMR Other
method will not List other
meet PN
requirements. You Did you have a consultation with MassDEP? Yes No Consultation date
must directly deliver
PN b hand
Yes
your y an ,
land, or electronic. The PN can be found on page of the CCR. Date of PN Occurrence NON Number
I am reporting multiple Tier 3 PNs. I have listed the additional PN information at the end i
The public water system indicated above hereby affirms that a Tier 3 public notice has bee
consumers in accordance with 310 CMR 22.16(4) including: delivery, content, format requ
deadlines, and that the public water system will meet future requirements for notifying neti
customers of the violation.
If you
watertidnotsell C. For Systems Selling Water to Other Community Water Systems
water to another
community PWS
skip Section C. My system delivered the applicable information required at 310 CMR 22.16A(3), to the
than April 1 st of this year, or by the mutually agreed upon date specifically included in a wr
parties.
D. Annual Cross Connection Education
Is this CCR being used for your system's annual cross -connection education? es No
If no, what methods did you use to meet your annual CCCP requirements (citation)?
Continued on next page
ALL distribution E. Consumer DeliveryMethods — Based on Population Served
(posting, land p
mail, or e -
delivery, For systems serving fewer than 500 persons: C 12'•617 Date of d,
publication, and (Choose 91 or #2)
good
faith efforts)
mbe1. My system used one or more of the following methods to notify customers that their
completed on or directly to them but is available to them upon request. (the notice is attached)
before July V.
Land -mail Door-to-door Newspaper entail osted notices
Instructions for
customers to LocaWns of posted notices H414 JL�E, /N�/Erequest a hard fiA(L NORTf/ 6V#46 i-16,44 w/Nt
copy must also
be included in 2. My system provided a CCR to each customer by the following method(s):
e -delivery.
Published the full CCR in a local newspaper (the published report from newspaper is s
eDelivered the CCR
Land -mailed or hand -delivered the CCR to consumers.
When a URL is
used it must be a e -Mailed with the CCR either embedded in the email or attached as a PDF. (e-mail is
direct link to the
document; no other Posted the CCR on the web and sent the direct URL to customers by way of land -mail
clicks allowed. attached).
List URL
For systems serving 500 to 9,999 persons: Date of dt
(Choose either #1 or #2)
1. My system provided a copy of the CCR to each customer by:
Land -mail a -Mail with PDF of CCR a -Mail with embedded CCR
Sent a notice (by land or e-mail) containing a direct URL to customers (copy is atts
List the URL if used.
2.My system provided the CCR to each customer by publishing the full report in a new;
published CCR is attached) and provided notice to consumers of this action by either:
Published a notice of this in a local newspaper
Land mailed a notice of this to consumers.
e -Mailed a notice of this to consumers.
For systems serving 10,000 or more persons: Date of deiivery/pubiicatior
My system provided a copy of the CCR to each customer by:
Land mail a -Mail with PDF a -Mail with embedded CCR
Sent a notice (by land or e-mail) containing a direct URL to customers
List the URL if used.
For systems serving greater than 100,000 population: In addition to one of the delivery
have posted the CCR on a publicly accessible Internet site as required.
WWW.
List the URL used
Continued on next page
F. Good Faith Delivery Methods (minimum of 3 is required for any sized systems)
Good Faith efforts To reach people who drink our water but are not billed customers the following were condL
are in addition to required delivery:
your primary Posted the CCR on a publicly accessible Internet site at the following address. (Only fi
method of delivery. p y g ( y
population who did not use this method as their primary method)
List the URL used
All systems must
submit CCR to
these three
agencies
Agencies and
consumers must
receive CCR on or
before July 1.
Mailed the CCR to all postal patrons within the service area (list of zip codes used is a.
Mailed a postcard listing the URL where the CCR can be found, to all postal patrons w
zip codes used is attached).
www.
List the URL used.
Advertised availability of the CCR in the following news media (the announcement is a
Radio Newspaper Television / cable Social media Digital signboard
Published the CCR in local newspaper (attach the published CCR).
Posted the CCR in public places i.e., post office, town hall, library (list of locations is ai
Delivered multiple CCR copies to single -bill addresses serving several persons i.e., ap
private employers (list of locations is attached).
Delivered multiple CCR copies to community organizations ( list of organizations is att<
4- Posted the CCR or a notice of availability at locations within the apartment/condo coml
attached).
+ Deliver CCR to new residents when they move in.
Other NO y A VA t I-Pk31 t. 1 rY / N 4 6-kig 1 CTTIFd2
G. Mandatory Agency Delivery Requirements
Local Board of Health
Deliver 1 copy of CCR and the Certification Form (Contact your board of health as
they would prefer hardcopy or e -delivery of CCR.)
2. MA Dept. of Public Health
Deliver 1 -copy of CCR and the Certification Form
PDF emailed to: dph.ccr(@mass.gov
or
Hardcopy to: 250 Washington St., Boston, MA 02108
Fore -delivery, soon
documents into 1 3. MassDEP Boston Office
PDF file. Make sure Deliver 1 copy of CCR, the Certification Form, and all needed attachments
Cert Form olfirstlowing
with CCR folPDF emailed to: Program.Director-DWP(cDmass.aov.
It. Label it [(PWSID)(PWS Name)(YEAR)CCR]
or
Hardcopy to: MassDEP-CCR Program, 1 Winter St. -5th FI., Boston, MA 02108
--Do not send to MassDEP regional offices --
Only Boston is accepting CCRs
Cl