3930-FM-BSDW0532
Rev. 10/2015
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF SAFE DRINKING WATER
RTCR SEASONAL START-UP ANNUAL CERTIFICATION FORM
Seasonal Public Water System Name:
PWS ID #:
Note: Contact the appropriate DEP district office if you close later than the season end date specified in your
Seasonal Start-Up Procedures.
Certification:
As a representative of the Public Water System (PWS) indicated above, I certify the following:

For this calendar year, the PWS has a season begin date of

Approved start-up procedures were completed.

Coliform sample(s) were collected at the location(s) specified in the system’s start-up procedure.

The most recent set of samples collected were absent of coliform bacteria.
Signature:
.
Date:
Print Name and Title:
Phone Number:
Complete and submit this form to the appropriate DEP district office prior to serving water to the public each
season.
The form should be mailed to DEP – Safe Drinking Water, at the appropriate district office address from the list on
the back of this form. For counties marked with an asterisk (*), address to the appropriate County Health Department
(CHD), which is an agent of DEP for the Safe Drinking Water Program.
-1-
3930-FM-BSDW0532
Instructions
Rev. 10/2015
DEP Office and County Health Department Contact Information by County
County
Adams
Allegheny
Armstrong
Beaver
Bedford
Berks
Blair
Bradford
Bucks
Butler
Cambria
Cameron
Carbon
Centre
Chester
Clarion
Clearfield
Clinton
Columbia
Crawford
Cumberland
Dauphin
Delaware
Elk
Erie
Address
York District Office
150 Roosevelt Ave., Suite 200, York, PA 17401
Allegheny County Health Department
3901 Penn Ave., Building 5, Pittsburgh, PA 15224
New Stanton District Office
131 Broadview Rd., New Stanton, PA 15672
Beaver Falls District Office
715 15th St., Beaver Falls, PA 15010
Altoona District Office
3001 Fairway Dr., Altoona, PA 16602
Reading District Office
1005 Cross Roads Blvd., Reading, PA 19605
Altoona District Office
3001 Fairway Dr., Altoona, PA 16602
Mansfield District Office
600 Gateway Dr., Mansfield, PA 16933
Southeast Regional Office
2 E. Main St., Norristown, PA 19401
New Castle District Office
121 N. Mill St., New Castle, PA 16101
Cambria District Office
286 Industrial Park Rd., Ebensburg, PA 15931
Moshannon District Office
186 Enterprise Dr., Philipsburg, PA 16866
Pottsville District Office
5 W. Laurel Blvd., Pottsville, PA 17901
Moshannon District Office
186 Enterprise Dr., Philipsburg, PA 16866
Southeast Regional Office
2 E. Main St., Norristown, PA 19401
Knox District Office
PO Box 669, Knox, PA 16232
Moshannon District Office
186 Enterprise Dr., Philipsburg, PA 16866
Moshannon District Office
186 Enterprise Dr., Philipsburg, PA 16866
Sunbury District Office
309 N. 5th St., Suite D, Sunbury, PA 17801
Northwest Regional Office
230 Chestnut St., Meadville, PA 16335
York District Office
150 Roosevelt Ave., Suite 200, York, PA 17401
Southcentral Regional Office
909 Elmerton Ave., Harrisburg, PA 17110
Southeast Regional Office
2 E. Main St., Norristown, PA 19401
Warren District Office
321 N. State St., North Warren, PA 16365
For Community & Nontransient PWS: For Transient PWS:
Note: address differs Warren District Office
depending on system 321 N. State St.
type
North Warren, PA 16365
Erie County Health Dept.
Drinking Water Program
606 W. Second St., Erie, PA 16507
-2-
Telephone #
717-771-4481
412-578-8047
724-925-5500
724-847-5271
814-946-7292
610-916-0100
814-946-7292
570-662-0830
484-250-5980
724-656-3160
814-472-1900
814-342-8200
570-621-3118
814-342-8200
484-250-5980
814-797-1191
814-342-8200
814-342-8200
570-988-5500
814 -332-6899
717-771-4481
717-705-4708
484-250-5980
814-723-3273
Warren:
814-723-3273
Erie CHD:
814-451-6700
3930-FM-BSDW0532
Instructions
County
Fayette
Forest
Franklin
Fulton
Greene
Huntingdon
Indiana
Jefferson
Juniata
Lackawanna
Lancaster
Lawrence
Lebanon
Lehigh
Luzerne
Lycoming
McKean
Mercer
Mifflin
Monroe
Montgomery
Montour
Northampton
Northumberland
Perry
Rev. 10/2015
Address
California District Office
25 Technology Dr., Coal Center, PA 15423
Warren District Office
321 N. State St., North Warren, PA 16365
York District Office
150 Roosevelt Ave., Suite 200, York, PA 17401
York District Office
150 Roosevelt Ave., Suite 200, York, PA 17401
California District Office
25 Technology Dr., Coal Center, PA 15423
Altoona District Office
3001 Fairway Dr., Altoona, PA 16602
Cambria District Office
286 Industrial Park Rd., Ebensburg, PA 15931
Knox District Office
PO Box 669, Knox, PA 16232
Southcentral Regional Office
909 Elmerton Ave., Harrisburg, PA 17110
Scranton District Office
321 Spruce St., Suite 300, Scranton, PA 18503
Lancaster District Office
1661 Old Philadelphia Pike, Lancaster, PA 17602
New Castle District Office
121 N. Mill St., New Castle, PA 16101
Lancaster District Office
1661 Old Philadelphia Pike, Lancaster, PA 17602
Bethlehem District Office
4530 Bath Pike, Bethlehem, PA 18017
Northeast Regional Office
2 Public Square, Wilkes-Barre, PA 18701
Northcentral Regional Office
208 W. Third St., Suite 101, Williamsport, PA 17701
Warren District Office
321 N. State St., North Warren, PA 16365
Southern Mercer County:
Northern Mercer County:
New Castle District Office
Northwest Regional Office
121 N. Mill St.
230 Chestnut St.
New Castle, PA 16101
Meadville, PA 16335
Altoona District Office
3001 Fairway Dr., Altoona, PA 16602
Pocono District Office
2174B Route 611, Swiftwater, PA 18370
Southeast Regional Office
2 E. Main St., Norristown, PA 19401
Sunbury District Office
309 N. 5th St., Suite D, Sunbury, PA 17801
Bethlehem District Office
4530 Bath Pike, Bethlehem, PA 18017
Sunbury District Office
309 N. 5th St., Suite D, Sunbury, PA 17801
Southcentral Regional Office
909 Elmerton Ave., Harrisburg, PA 17110
-3-
Telephone #
724-769-1100
814-723-3273
717-771-4481
717-771-4481
724-769-1100
814-946-7292
814-472-1900
814-797-1191
717-705-4708
570-963-4521
717-299-7601
724-656-3160
717-299-7601
610-861-2070
570-826-2511
570-327-3490
814-723-3273
New Castle:
724-656-3160
Meadville:
814-332-6899
814-946-7292
570-895-4040
484-250-5980
570-988-5500
610-861-2070
570-988-5500
717-705-4708
3930-FM-BSDW0532
Instructions
County
Philadelphia
Pike
Potter
Schuylkill
Snyder
Somerset
Sullivan
Susquehanna
Tioga
Union
Venango
Warren
Washington
Wayne
Westmoreland
Wyoming
York
Rev. 10/2015
Address
Southeast Regional Office
2 E. Main St., Norristown, PA 19401
Pocono District Office
2174B Route 611, Swiftwater, PA 18370
Mansfield District Office
600 Gateway Dr., Mansfield, PA 16933
Pottsville District Office
5 W. Laurel Blvd., Pottsville, PA 17901
Sunbury District Office
309 N. 5th St., Suite D, Sunbury, PA 17801
Cambria District Office
286 Industrial Park Rd., Ebensburg, PA 15931
Northcentral Regional Office
208 W. Third St., Suite 101, Williamsport, PA 17701
Scranton District Office
321 Spruce St., Suite 300, Scranton, PA 18503
Mansfield District Office
600 Gateway Dr., Mansfield, PA 16933
Sunbury District Office
309 N. 5th St., Suite D, Sunbury, PA 17801
Northwest Regional Office
230 Chestnut St., Meadville, PA 16335
Warren District Office
321 N. State St., North Warren, PA 16365
Beaver Falls District Office
715 15th St., Beaver Falls, PA 15010
Scranton District Office
321 Spruce St., Suite 300, Scranton, PA 18503
New Stanton District Office
131 Broadview Rd., New Stanton, PA 15672
Northeast Regional Office
2 Public Square, Wilkes-Barre, PA 18701
York District Office
150 Roosevelt Ave., Suite 200, York, PA 17401
-4-
Telephone #
484-250-5980
570-895-4040
570-662-0830
570-621-3118
570-988-5500
814-472-1900
570-327-0540
570-963-4521
570-662-0830
570-988-5500
814-332-6899
814-723-3273
724-847-5271
570-963-4521
724-925-5500
570-826-2511
717-771-4481