Reporting Forms

Annual Pumpage/Usage Report in Word or PDF
Community water supplies that do not submit a monthly operation report must submit a report of annual water pumpage and use to the DEQ district office by March 31 of each year.

Cross Connection Report 
Community water supplies must report annually on the status of their cross connection program to the DEQ district office by March 31 of each year.  Download the appropriate version of the form:

  • Cross Connection Report in Word or PDF
  • Cross Connection Report for Systems Serving Only Residential Accounts in Word or PDF

Revised Total Coliform Rule - Sample Siting Plan in Word or PDF (updated for RTCR)
Water supplies must have a current sample siting plan detailing sampling locations for routine and follow-up bacteriological monitoring.  If you have more than five (5) distribution sample sites, you may incorporate this sheet (PDF) as part of the SSP.

Revised Total Coliform Rule - Level 1 Assessment Form in Word or PDF
This form must be completed and submitted to the appropriate DEQ District Office as soon as possible, but no later than 30 days after the Level 1 Assessment is triggered.

Disinfectants and Disinfection Byproducts Monitoring Plan
Community water supplies that serve disinfected water must have a monitoring plan detailing sampling locations, sampling dates, and compliance calculation procedures for disinfectants and disinfection byproducts monitoring.

  • DDBP Monitoring Plan in Word or PDF
  • DDBP Monitoring Plan in Word or PDF for water plants treating surface water using conventional filtration
  • Instructions to complete the form

Lead and Copper Report and Consumer Notice of Lead Result Certificate: updated forms will be available soon
This form serves two purposes:

  • Report the lead and copper monitoring information on the template on pages 1 and 2 to the DEQ district office within 10 days of the end of the monitoring period.
  • Notify occupants of homes tested of the individual tap results using the template on page 4 within 30 days of knowing the results.  Certify to the DEQ that all requirements were met using the statement on the bottom of one example copy of a notice sent to a customer within 3 months of the end of the monitoring period.

Water Quality Parameters in Word or PDF:  Water supplies may report water quality parameter monitoring on the Monthly Operation Report or on this addendum to the Lead & Copper Report for Water Quality Parameters.

2018 CCR Template
Every community water supply must deliver a Consumer Confidence Report to consumers by July 1st annually. The report should include the most recent water quality data for the system within the last five (5) years.

CCR Certificate of Distribution in Word or PDF 
Community water supplies must submit a certificate to the DEQ district office immediately following delivery of the annual Consumer Confidence Report confirming that the CCR is correct and has been distributed as required.

Emergency Response Plan in Word or PDF 
This form replaces the Contingency Plan.  Community water supplies must prepare plans and procedures and identify personnel and equipment that can be used in the event of an emergency.  The Emergency Response Plan outlines a program for rapid correction or mitigation of emergencies to significantly lessen the impact of the emergency on the public health and the safety and supply of drinking water provided to the public.  Water supplies with a Contingency Plan will transition to the Emergency Response Plan according to the update schedule contained in the Contingency Plan.

Boil Drinking Water Public Notice Templates
Water supplies that need to issue a public notice should contact DEQ drinking water staff to ensure content and delivery requirements are met.

Stipulate to Conditions for Private Ownership of Public Water Supply
The owner of a privately owned Community Water Supply (CWS) must stipulate to conditions required by the department to ensure the CWS will meet the requirements of the act and rules.  The stipulation is required of owners of proposed water supplies, new owners of existing water supplies, and owners of water supplies whose classification is changed to CWS.  This stipulation is only one of many requirements on privately owned CWS.  Contact the appropriate Department of Environmental Quality (DEQ) district office to discuss requirements.

DEQ districts serving Community Water Supplies 
Addresses of the 8 DEQ district offices overseeing community water supplies and the counties they serve.
DEQ district map with telephone numbers of DEQ staff that oversee the community water supply program and the counties they serve.