04e_MassDEP_PWS_Certified_Operator_Compliance__Notice.pdf

iJ Important: When filling out forms on the computer, use only the tab key to move your cursor- do not use the return key.

PWS must complete the COCM and the appropriate "COD" Duty Form for the system.

See Instructions.

COCM

Massachusetts Department of Environmental Protection Bureau of Resource Protection - Drinking Water Program

Public Water System Certified City !Town

PWS Name

Operator Compliance Notice PWSID

A. Certification

Print Operator's Name

Operator's Signature Date

Print System Owner's Name and Title

System Owner's Signature Date

B. System Information

Public Water System Name PWS ID

Street Address

City !Town State Zip Code

Phone E-mail Address

System Type: 0 Community D Non-transient Non-community 0Transient Non-community

Population in Winter Population in Summer

Distribution Class: 0 I 011 0111 OIV OVND ovss

Treatment: 0 Yes 0 No Treatment Class: 01 011 0111 OIV

If yes, please specify treatment types and purpose of treatment and chemicals used:

C. Operator Information

Print Name

Street Address

City !Town State Zip Code

Phone E-mail Address

License# Grade 0 OIT or 0 Full cocm.doc- rev. 11-09 PWS Certified Operator Compliance Notice - Page 1 of 3

COCM

Massachusetts Department of Environmental Protection Bureau of Resource Protection - Drinking Water Program

City/Town

Public Water System Certified PWS Name

Operator Compliance Notice PWSID

D. Operator Information (cont'd)

Will assume responsibility as the [ D primary I D secondary ] operator for hours per day days per week/month and will be able to respond to an emergency within minutes.

Please list the names and PWS ID #'s of all other systems which you currently operate. (Attach list if necessary.)

Public Water System Name PWS ID#

Public Water System Name PWS ID#

Public Water System Name PWS ID#

Public Water System Name PWS ID#

Please describe any sanctions the Board has levied on your operator's license in the past 3 years:

E. Typical Duties and Responsibilities

Please choose the "Typical Duties and Responsibilities" (COD) sheet that applies to your system.

System owner and operator are to jointly complete the sheet that best describes the system. That sheet becomes part of this notice. The notice is not complete without this duties sheet attached.

Duties sheets are provided separately at http :1 lwww. mass. gov/dep/water/ap prova ls/dwsforms. htm#opcert.

Check appropriate form:

D COD-5

D COD-1

D COD-6

D COD-2

D COD-7

0 COD-3

D COD-8

0 COD-4

0 COD-9

F. Other Duties

List other duties to be operator's responsibility:

List other duties to be the system's responsibility:

cocm.doc- rev. 11-09 PWS Certified Operator Compliance Notice - Page 2 of 3

Small PWS Staffing and Comprehensive Operations Plan 310 CMR 22.11 8(2) and 22.11 8(5)

System Name: _ __________________ _

City/Town: _________ PWS ID#: _____ _

System Classification: COM D NTNC D C D (Check one)

Contract Operator(s) D Licensed Staff D No Certified Operator D (Check one)

Operator Name: Phone# ------------- -------- Grade/Cert# ______ _

*Backup Operator Name: Phone# --------- -------- Grade/Cert# ______ _

Give a brief description of proposed operating practices including the number of hours per day, week, or month that the licensed operator will be at the facility. Include the name and telephone number of the person accepted by the licensed operator who will be responsible for the system in the absence of the licensed operator. (See notes below for further information.)

Please note the following:

I. The primary operator must be able to respond to emergencies within one hour during those times when he or she is not present at the facili ty. *Backup operator should be identified so that when the primary operator is unavailable, operator coverage is maintained.

2. The primary operator is responsible for the operation of the system during his or her absence between scheduled visits. The person(s) affiliated with the public water system are acting under the direction of the primary operator.

3. The PWS must have the ability to detect any malfunction in the operation of the facil ity/system in the absence of the primary operator.

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.

Owner/System Representative Signature Date

Certified Operator Signature Date

Bureau of Resource Protection - Drinking Water Program

Public Water System Certified Operator Compliance Notice G. For MassDEP Use Only

MassDEP Office

Print Name Title

Signature Date

D Approved D Denied

Comments:

COCM

CityfTown

PWS Name

PWSID

Original gets mailed back to PWS; copy to certified operator; copy to MassDEP-Boston ; and copy for MassDEP-Region .

cocrn.doc- rev. 11-09 PWS Certified Operator Compliance Notice - Page 3 of 3