Fillable Certification of Delivery of Consumer Confidence Report (Department of Environmental Protection)

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Certification of Delivery of Consumer Confidence Report (Department of Environmental Protection)

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U.S.A. forms for Department of Environmental Protection

BROWSE DEPARTMENT OF ENVIRONMENTAL PROTECTION (FL) FORMS

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Certification of Delivery of Consumer Confidence Report
GENERAL INSTRUCTIONS: This form shall be completed by all community water systems (CWSs) that have
prepared a Consumer Confidence Report (CCR) in accordance with Rule 62-550.824, F.A.C., Consumer Confidence
Reports. At the end of this form is a certification in which a system’s authorized representative shall certify that the
reported information is accurate and is in conformance with Rule 62-550.824, F.A.C. COMPLETE THIS FORM AND
SUBMIT IT BY AUGUST 10, together with a copy of your system’s CCR, and any newspaper notice(s) and posted
notice(s) of your CCR, to the appropriate DEP district office or Approved County Health Department (ACHD). Systems
serving 100,000 or more persons posting their CCRs on publicly accessible Internet sites shall provide the information
on the appropriate Internet link(s). All information provided on this form must be typed or printed in ink.
I. General Water System Information. (To be completed by all community water systems.)
System name: Contact person:
PWS Identification number (PWS-ID): Contact phone number:
Mailing address: City:
State: Zip: Population served (not the number of “service connections”):
II. CCR Distribution Method. (To be completed by all community water systems. Choose A or B as
appropriate.)
A. We mailed or otherwise directly delivered a copy of our CCR to each customer on (enter date(s) of mailing or
delivery.) ___________ (Systems that do not use the mailing waiver must mail or otherwise directly deliver a copy
of their CCR to each customer.)
B. We were eligible to use a mailing waiver and used a mailing waiver. (Systems are eligible to use a mailing
waiver only if they serve fewer than 10,000 persons, have not had any MCL or monitoring and reporting (M/R)
violations, nor have been issued any formal Notices of Violations (NOVs), Consent Orders, Administrative
Orders, or court-ordered civil actions during the calendar year before the year the CCR is due to the customers.)
Answer a, b,
and
c below.)
a. Date of newspaper:
b.
Name of news
p
a
p
er/newsletter that
p
ublished our CCR:
c. A copy of our notice to customers, informing them that our CCR will not be mailed to them, is attached.
This notice was: mailed with bill; published in newspaper/newsletter; or other (describe)
III. Posting of CCR on the Internet. (To be completed by all CWSs serving 100,000 or more persons.)
We posted our CCR on this publicly accessible Internet Site:
IV. Report on Your Effort to Distribute Your CCR to Your Water Consumers.
(To be completed by all CWSs. Check all items that apply - at least 2 items must be checked.)
In addition to the methods selected in Part II,
A. We posted our CCR on this publicly accessible Internet
B. We
p
ublished our CCR in the local news
p
a
p
er
(
s
)
. The name
(
s
)
and date
(
s
)
of the news
p
a
p
er
(
s
)
are:
C. We advertised the availabilit
y
of our CCR as a
p
ress release, radio announcement, or TV announcement.
The type(s) and date(s) of the advertisement(s) are:
D. We delivered multi
p
le co
p
ies of our CCR to sin
g
le bill addresses servin
g
several
p
ersons.
E. We delivered multiple copies of our CCR to the following community organizations:
F. Our CCR was posted in the following public locations:
DEP Form 62-555.900(19)
Effective Date: April 10, 2003
Page 1 of
2
G. Our CCR was distributed by other methods (e.g., additional copies placed in entrance hall to facility). Describe.
V. Use of Non-English Language in CCR. (To be completed by all community water systems.)
Information in a non-English language was included in our CCR because 20% or more of our customers do not
speak English but speak
. The method we used to determine the proportion of
non-En
lish s
eakin
customers is
This re
q
uirement does not a
pp
l
y
to our s
y
stem, because we have no non-En
g
lish s
p
eakin
g g
rou
p
amon
g
our
customers equal to or exceeding 20% of our total number of customers.
VI. Other Delivery Requirements. (To be completed by all community water systems.)
(A) Was a copy of your CCR sent to your county health department, as required by rule? Yes No
(B) Is your system regulated by the Public Service Commission (PSC)? Yes No
If Yes, was a copy of your CCR sent to the PSC, as required by rule?
Yes No
(C) If your system sells water to other systems, have you provided them with either a copy of your CCR or the
required consumer confidence information? Yes No Not Applicable
VII. Certification of Delivery of CCR and Compliance with Regulations. (To be completed by all CWSs.)
This statement certifies that the above named community public water system has distributed its CCR for the time
period starting January 1, , and ending December 31, , to its customers on (mm/dd/yy) __________ and
provided the appropriate notices of availability according to the requirements listed in this form, which are also found in
Rule 62-550.824, F.A.C. This statement also certifies that the reported information is correct and consistent with the
compliance monitoring data for the same period previously submitted to the Department, and that the report has been
delivered to the agencies identified in Rules 62-550.824(3)(e)3., and 4., F.A.C.
SIGNATURE OF AUTHORIZED REPRESENTATIVE:
NAME (please print):
TITLE: DATE:
A copy of our CCR is attached.
DEP Form 62-555.900(19)
Effective Date: April 10, 2003
Page 2 of
2
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Certification of Delivery of Consumer Confidence Report (Department of Environmental Protection)

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Completed 30 June 2021

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