349 PWS 1214001 2021 Linda Manor Certification FormMassDEP
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VSS PWS note: if
you deliver your
CCR by newspaper
or postings, that
method will not
meet PN
requirements. You
must directly deliver
your PN by hand,
land, or electronic.
Massachusetts Department of Environmental Protection
Bureau of Resource Protection — Drinking Water Program
Consumer Confidence Report Certification
For calendar year 2020
A. PWS Information
Linda Manor 1214001
PWS Name PWS ID
Leeds 120
City /Town
Max population
The community water system named above
Jeff Hildreth
hereby certifies that its Consumer Confidence
Name
Report (CCR) was distributed to customers,
Certified Drinking Water Operator
appropriate agencies, and notices of availability
Title
have been given in compliance with 310 CMR
413-219-0982
22.16A. Furthermore, the system certifies that
Phone
the information contained in the report is correct
ieffhil14@yahoo.com
and consistent with the compliance monitoring
E -Mail
data previously submitted to MassDEP.
6_/22/2022
1 certify under penalty of law that I am the person
Date
authorized to fill out this form and the information
contained herein is true, accurate, and complete to
�__�� "'s
the best of my knowledge and belief.
Sig re of Owner/Responsible Party or Certified Operator
B. Public Notice Certification
Is this system using this CCR to provide Tier 3 Public Notice to their customers? ❑ Yes ® No
The PN is for a: Violation ❑ UCMR ❑ Other ❑
Did you have a consultation with MassDEP ? ❑ Yes ❑ No
The PN can be found on page of the CCR.
List other
Consultation date
Date of PN Occurrence NON Number
❑ I am reporting multiple Tier 3 PNs. I have listed the additional PN information at the end of this form.
The public water system indicated above hereby affirms that a Tier 3 public notice has been provided
within this CCR to consumers in accordance with 310 CMR 22.16(4) 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 violation.
If you did not sell
water to another C. For Systems Selling Water to Other Community Water Systems
community PWS M system delivered the applicable information required at 310 CMR 22.16A 3 to the buying
skip section C. ❑ Y Y Pp q ()� Y 9
system(s) no later than April 1 st of this year, or by the mutually agreed upon date specifically included in
a written contract between the parties.
D. Annual Cross Connection Education
Is this CCR being used for your system's annual cross -connection education? ® Yes ❑ No
If no, what methods did you use to meet your annual CCCP requirements (citation)?
Continued on next page
Rev 2021-02 Page 1 of 3
ALL distribution
(posting, land E. Consumer Delivery p Methods — Based on Population Served
mail, or e -
delivery, For systems serving fewer than 500 persons:
publication, and (Choose #1 or #2) Date of delivery/publication: b ! Z 7 iZ Z
good faith efforts) ® 1. My system used one or more of the following methods to notify customers that their CCR would
must be not be mailed direct) to them but is available to them upon request. the notice is attached
completed on or y p q ( )
before July I".
❑ Land -mail ❑ Door-to-door ❑ Newspaper ❑ eMail ® Posted notices
Instructions for Main Entrance, Dining Hall, North Wing and South Wing__ _
customers to Locations of posted notices
request a hard
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 attached).
❑ 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 attached)
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 or email
clicks allowed- (notice/postcard is attached).
List URL
For systems serving 500 to 9,999 persons:
(Choose either #1 or #2) Date of delivery/publication: mmldd/yyyy
❑ 1. My system provided a copy of the CCR to each customer by:
❑ Land -mail ❑ e -Mail with PDF of CCR ❑ e -Mail with embedded CCR
❑ Sent a notice (by land or e-mail) containing a direct URL to customers (copy is attached)
List the URL if used.
❑ 2.My system provided the CCR to each customer by publishing the full report in a newspaper (a copy
of the 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 delivery/publication: mm/dd/yyyy
❑ My system provided a copy of the CCR to each customer by:
❑ Land mail ❑ e -Mail with PDF ❑ e -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 methods
checked above, we have posted the CCR on a publicly accessible Internet site as required.
www.
List the URL used
Rev 2021-02 Page 2 of 3
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 conducted in
are in addition to
your primary addition to the required delivery:
method of delivery. ❑ Posted the CCR on a publicly accessible Internet site at the following address. (Only for systems
under 100,000 population who did not use this method as their primary method)
www.
List the URL used.
❑ Mailed the CCR to all postal patrons within the service area (list of zip codes used is attached).
❑ Mailed a postcard listing the URL where the CCR can be found, to all postal patrons within the
service area (list of zip codes used is attached).
www.
List the URL used.
❑ Advertised availability of the CCR in the following news media (the announcement is attach):
❑ 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 attached).
❑ Delivered multiple CCR copies to single -bill addresses serving several persons i.e., apartments,
businesses, large private employers (list of locations is attached).
❑ Delivered multiple CCR copies to community organizations ( list of organizations is attached.)
® Posted the CCR or a notice of availability at locations within the apartment/condo complex (list of the
locations is attached).
® Deliver CCR to new residents when they move in.
® Noted availability in newsletter
Other
All systems must G. Mandatory Agency Delivery Requirements
submit CCR to
these three ® 1. Local Board of Health
agencies Deliver 1 copy of CCR and the Certification Form (Contact your board of
health as to whether they would prefer hardcopy or e -delivery of CCR.)
® 2. MA Dept. of Public Health
Agencies and
consumers must Deliver 1 -copy of CCR and the Certification Form
receive CCR on or ❑ PDF emailed to: dph.ccr(cDmassmail.state. ma. us
before July 1. or
❑ Hardcopy to: 250 Washington St.; Boston, MA 02108
For e -delivery, scan ® 3. MassDEP Boston Office*
documents into 1 Deliver 1 copy of CCR, the Certification Form, and all needed attachments
PDF file. Make sure ❑ PDF emailed to: Program. Director-DWP(astate.ma. us.
Cert Form is first Label it [PWSID-PWS Name -year -CCR]
with CCR following or
it.
❑ Hardcopy to: MassDEP-CCR Program, 1 Winter St. -5x"` FL; Boston, MA
*Because of 02108
COVID-19
restrictions, the --Do not send to MassDEP regional offices --
preferred delivery Only Boston is accepting CCRs
method is email
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Date completed
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Date completed
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Date completed
Rev 2021-02 Page 3 of 3