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Reporting Forms

application form
Environment, Great Lakes, and Energy

Reporting Forms

Submit your completed document(s) to EGLE via your Michigan Environmental Health and Drinking Water Information System (MiEHDWIS) account, or via email to your EGLE district office email address. Join the many Community Water Supplies around the state that have already begun utilizing MiEHDWIS. MiEHDWIS will be your workspace to submit results, reports, permit applications, and more, track the progress of those submissions, and communicate with EGLE staff. Some forms are now available for direct entry into MiEHDWIS. For more information on MiEHDWIS, please visit Michigan.gov/EGLE-MiEHDWIS.

Form Type Supporting Materials
Annual Pumpage/Usage Report
Community water supplies that do not submit a monthly operation report must submit a report of annual water pumpage and use to your EGLE District Office by March 31st of each year.
Annual Service Line Replacement Report Form
Water supplies with lead or galvanized previously connected to lead (GPCL) service lines shall annually provide the department a summary of service line repairs or replacements. This form must be submitted by March 31st every year.
Boil Drinking Water Public Notice Templates
Water supplies that need to issue a public notice should contact EGLE Drinking Water staff to ensure content and delivery requirements are met.
CCR Certificate of Distribution
Community water supplies must submit a certificate to your EGLE District Office immediately following delivery of the annual Consumer Confidence Report confirming that the CCR is correct and has been distributed as required.
CCR Template
Every community water supply must delivery 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.
Cross Connection Report
Community water supplies must report annually on the status of their cross connection program to your EGLE District Office by March 31st of each year.
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.
Drinking Water Emergency Report
Public water supplies must file a written report with EGLE within 90 days of an emergency. An "emergency" includes situations that result in contamination, loss of pressure, lack of adequate water supply, or other condition that poses an imminent hazard or danger to public health.
Emergency Response Plan
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 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 updated schedule contained in the Contingency Plan.
Lead and Copper Report and Consumer Notice of Lead Result Certificate
Water supplies must report lead and copper monitoring information within 10 days of the end of the monitoring period. This form should be used to meet this requirement. Use of Form A or B is dependent on whether a supply does or does not have lead service lines.
Lead and Copper Sampling Plan Form
Water supplies must identify a pool of lead and copper sampling sites that targets high risk sites based on the tiering criteria in R325.10710a(1). This plan must contain at least the number of sites required for standard monitoring based on the supply's population. The plan is a living document and must be updated and submitted to EGLE as necessary.
Operator Designation Form for Community Water Supplies
Administrative Rule R 325.11905(1) requires water supplies to be under the supervision of an operator in charge (OIC), certified in the system classification. Please use this form to designate an OIC, back-up operator, or if appropriate, a back-up operations plan.
Preliminary DSMI Reporting Form
By January 1, 2020, water supplies were required to complete a preliminary Distribution System Materials Inventory (DSMI). This inventory will estimate the number of high-risk service lines and describe the reliability of existing records, thereby providing important information for planning service line verification and replacement efforts.
Preliminary DSMI Interim Update Form (Optional)
The purpose of this “Interim Update” form is to provide a format for water supplies to submit an optional update to the information provided in their PDSMI submittal.
Public Notice Certification of Distribution
Public water supplies must report a certificate of distribution and a copy of the Public Notice that was distributed to the Michigan Department of Great Lakes and Energy within 10 days of notifying customers. The Public Notice Certificate of Distribution will aid in accomplishing the Public Notice distribution for Tier 2 and Tier 3 violations. More information on the Public Notice Rule requirements can be found by visiting Public Notification Rule.
Revised Total Coliform Rule - Sample Siting Plan (SSP)
Water supplies must have a current sample siting plan detailing sampling locations for routine and follow-up bacteriological monitoring. The SSP form is now available in MiEHDWIS! Please login to MiEHDWIS, create a Bacteriological Sample Site Plan Work Item, and enter the site information directly into the form in the system. For more information on MiEHDWIS, please visit Michigan.gov/EGLE-MiEHDWIS. For water supplies not yet in MiEHDWIS, use the documents on the right.
Revised Total Coliform Rule - Level 1 Assessment Form
This form must be completed and submitted to your EGLE District Office as soon as possible, but no later than 30 days after the Level 1 Assessment is triggered.
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 acts 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 the many requirements on privately owned CWS. Contact the appropriate EGLE District Office to discuss requirements.
  • Form A: Supplies NOT LICENSED by the State of Michigan
  • Form B: Supplies LICENSED by the State of Michigan (e.g. MHCs, health care facilities, etc.)
Water Quality Parameter Report
Water supplies must report water quality parameter (WQP) monitoring within 10 days of the end of the monitoring period. Since WQP monitoring involves a mix of results that were collected in the field, done by benchtop analysis, or sent to a certified lad, a water supply can report lab results, their Monthly Operation Report, or using the following forms to meet this requirement. Use the form for supplies with corrosion control or without corrosion control based on the water system's treatment.