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Reporting Forms

application form
Environment, Great Lakes, and Energy

Reporting Forms

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.
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
Lead and Copper reporting forms are available on the Lead and Copper Rule webpage.
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. 
Revised Total Coliform Rule - Sample Siting Plan (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 the Distribution Sample Sites Continued sheet as part of the SSP.
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.)