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Office of Drinking Water Forms

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Forms on this page are only available by downloading through the links below. They cannot be ordered through our office or through our on-line publication ordering system.

If you have questions concerning an Office of Drinking Water form contact your regional office.

 
Files below are under 200 KB in file size unless otherwise stated.  

Adequacy

331-291 - Water System Adequacy Request Form - Southwest Regional Office (PDF)
331-292 - Water System Adequacy Request Form - Northwest Regional Office (PDF)
331-293 - Water System Adequacy Request Form - Eastern Regional Office (PDF)

331-321 - Adequacy Request Form - Lending Institutions and Realtors (Word)
331-321 - Adequacy Request Form - Lending Institutions and Realtors (PDF)

Consumer Confidence Report

331-203 Consumer Confidence Report Certification Form (Word)
331-203 Consumer Confidence Report Certification Form (PDF)

Cross Connection

331-243 - Cross-Connection Control Program Backflow Incident Report

Drinking Water State Revolving Fund 2008

331-201 Drinking Water State Revolving Fund 2008 Funding Cycle Application (Word)
331-201 Drinking Water State Revolving Fund 2008 Funding Cycle Application (PDF)

Engineering and Planning Submittals

331-121 - Construction Completion Report (Word)
331-121 - Construction Completion Report (PDF)

331-122 - Engineering Design Review Report (For Distribution-Related Project Submittal Exceptions) (Word)
331-122 - Engineering Design Review Report (For Distribution-Related Project Submittal Exceptions) (PDF)

331-146 - Construction Completion Report Form for Submittal Exception Process
(Word)
331-146 - Construction Completion Report Form for Submittal Exception Process
(PDF)

331-147 - Construction Completion Report Form for Distribution Main Projects
(Word)
331-147 - Construction Completion Report Form for Distribution Main Projects (PDF)

331-149 - WA State Dept. of Health, Project Approval Application (Word)
331-149 - WA State Dept. of Health, Project Approval Application (PDF)

331-396 -  Small Water System Management Program Submittal (Word)

331-397 - Water System Plan Submittal (Word)

Water Rights Self Assessment

Instructions for Completing the Water Rights Self Assessment Forms
(Word)

331-370 - Project Report Form - Water Rights Self Assessment (Word)
331-370 - Project Report Form - Water Rights Self Assessment (PDF)

331-371 - Water System Plan - Water Rights Self Assessment - Existing Status (Word)
331-371 - Water System Plan - Water Rights Self Assessment - Existing Status (PDF)

331-372 - Water System Plan - Water Rights Self Assessment--6 Year Forecast (Word)
331-372 - Water System Plan - Water Rights Self Assessment--6 Year Forecast (PDF)

331-373 - Water System Plan - Water Rights Self Assessment--20 Year Forecast (Word)
331-373 - Water System Plan - Water Rights Self Assessment--20 Year Forecast (PDF)

Groundwater Under the Influence of Surface Water

331-189 - Potential GWI Source Identification and Designation(PDF)
331-190 - GWI Determination Process Purveyor's Choice (PDF)
331-191 - GWI Quality Monitoring Interview Documentation (PDF)
331-192 - GWI Water Quality Monitoring Confirmation (PDF)
331-193 - GWI Water Quality Monitoring Report Form (PDF)
331-194 - GWI Hydraulic Connectivity Determination, Analysis of Water Quality Monitoring Date (PDF)
331-195 - GWI Hydraulic Connectivity Determination, Descriptive Statistics (PDF)

Public Notification

331-248 - Public Notice Certification Form Nitrate MCL Violation (PDF)

331-263 - Coliform Maximum Contaminant Level Exceeded: Non-Acute MCL (PDF)

331-264 - Public Notice Certification Acute Coliform MCL (PDF)

331-346 - Notice to Water System Users: Quarterly Nitrate Monitoring Violation (Word)
331-346 - Notice to Water System Users: Quarterly Nitrate Monitoring Violation (PDF)

331-347 - Lead and Copper Monitoring Violation - English and Spanish (Word)

331-354 - Lead and Copper Initial Monitoring Violation (PDF)

331-357 - Notice to Water System Users: Annual Nitrate Monitoring Violation (Word)
331-357 - Notice to Water System Users: Annual Nitrate Monitoring Violation (PDF)

331-360 - Disinfection Byproducts Monitoring Violation (PDF)
331-360 - Disinfection Byproducts Monitoring Violation (Word)

331-394 - Monthly Bromate Monitoring Violation (PDF)
331-394 - Monthly Bromate Monitoring Violation (Word)

331-395 - Quarterly Total Trihalomethane (TTHM)/Haloacetic Acids (HAA5) Monitoring Violation (PDF)
331-395 - Quarterly Total Trihalomethane (TTHM)/Haloacetic Acids (HAA5) Monitoring Violation (Word)

Surface Water Treatment Forms - You will need Microsoft Excel 97 or a later version on your computer to use these forms.

#331-023 - Water Treatment Plant Monthly Report Summary
#331-048 -
SWTR Disinfection Monthly Report 
#331-172 -
Surface Water Treatment Plant Monthly Report Summary
Excel file includes CT look up table.

The three forms above (#331-023, #331-048 & #331-172) are contained in one Excel workbook file. After opening the file, note the four tabs at the bottom. The first tab (Cover Page and Notes) contains the directions on use of the forms. Open and read it first. Then click on the other tabs to access the forms.

Open the Excel Workbook (507 KB) and view the directions (Cover Page and Notes) and forms above.

Water Quality

Coliform

331-319 - Coliform Bacteria Analysis Form Templates

Disinfection Byproducts

331-341 - Disinfection Byproduct Monitoring Plan (Excel 119 KB). The two organizations below can provide assistance with completing this form.

Evergreen Rural Water of Washington (ERWOW)
Rural Community Assistance Corporation (RCAC)

Epichlorohydrin and Acrylamide

331-337 - Certification Form of Epichlorohydrin and Acrylamide Usage
(Word)
331-337 - Certification Form of Epichlorohydrin and Acrylamide Usage
(PDF)

Water Use Efficiency

#331-376 - Annual Water Use Efficiency Performance Report (Word)

 

 


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Dept. of Health
Office of Drinking Water
243 Israel Road S.E. 2nd floor
Tumwater, WA 98501
Mail:
P.O. Box 47822
Olympia, WA 98504-7822
(360) 236-3100

Send inquiries about DOH and its programs to the Health Consumer Assistance Office
Comments or questions regarding this Web site? Send mail to Judy J. Sides.

Last Update : 05/13/2008 10:31 AM