3930-FM-BSDW0181 9/2015
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF SAFE DRINKING WATER
Tier 1 Public Notice
PREPAREDNESS CHECKLIST
System Name:
PWS ID:
System Size:
Contact Name:
Phone Number:
Completed By:
Date:
One Hour Reporting Requirements §109.701(a)(3):
1. Do you have the necessary DEP contact information to report imminent
threat violations/situations to DEP within 1 hour, including after
hours and weekends? (i.e., 24/7 DEP emergency phone numbers)
Yes
No
Yes
No
Emergency Response Plan (ERP) Requirements §109.707:
2. Do you have an ERP?
3. Date of last update
/
4. Does the ERP include identification of probable emergencies?
/
Yes
No
5. Does the ERP include corrective actions or probable solutions to
respond to the emergencies listed above?
Yes
No
6. Does the ERP include procedures for communicating and
coordinating with local emergency management personnel?
Yes
No
7. Does the ERP include provisions for notifying key public officials?
Yes
No
Yes
No
Please list, in general terms, the probable emergencies (i.e., failure
of key treatment processes, outages, chemical spills, natural disasters):
Operation and Maintenance (O&M) Plan Requirements §109.702:
8.
Do you have an O&M Plan?
9.
Date of last update
/
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/
3930-FM-BSDW0181 9/2015
10.
Does the O&M Plan include a Public Notification Program
that consists of:

Tier 1 public notice templates;
Yes
No

An explanation of appropriate methods of delivery; and
Yes
No

A designation of public notice recipients for Tier 1
violations/situations?
Yes
No
Yes
No
Please list the titles of your Tier 1 PN templates (i.e., nitrate MCL
exceedance):
Please describe the appropriate Tier 1 methods of delivery:
Please list the public notice recipient types that have been identified,
including vulnerable subgroups (i.e., hospitals, schools):
Comments:
For DEP Use Only
Is additional follow-up required?
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3930-FM-BSDW0181 9/2015
VERIFICATION ON BEHALF OF PUBLIC WATER SYSTEM REGULATED BY
THE DEPARTMENT OF ENVIRONMENTAL PROTECTION
I,
, state that I am the
the
(title) of
(legal name) Public Water System, that I am authorized
to make this affidavit on its behalf and that the facts set forth in the foregoing Safe Drinking
Water Act Tier I Public Notification Preparedness document are true upon my personal
knowledge, information and belief.
I understand that my statements are made subject to 18 Pa. C.S.A. Sec. 4904 providing
for criminal penalties for unsworn falsification to authorities.
Date
Signature
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