Reporting Forms for Drinking Water Systems in Wyoming and Tribal Lands in EPA Region 8

Related Information

Use the documents in this section to report on water system operational activities. For more information, please contact us.

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Changes to Public Water Systems (CHG)

Form Description
PWS Inventory Change Form PWS Inventory Change Form - This form should be completed and submitted to EPA Region 8 when a Public Water System in Wyoming or located on Tribal Lands in EPA Region 8 (CO, MT, ND, SD, UT or WY) is making changes to: Source, Treatment, Water System Facilities or Management.
PWS Contact Change Form PWS Contact Change Form - This form should be completed and submitted to EPA Region 8 when there is a change to management or other contact information for a Public Water System in Wyoming or located on Tribal Lands in EPA Region 8 (CO, MT, ND, SD, UT or WY). 
Seasonal Operational Change Form Seasonal Operational Change Form - This form should be completed and submitted to EPA Region 8 when a Public Water System is making permanent changes to the season they are serving water to the public. 
Surface Water/GWUDISW Change Form Surface Water/GWUDISW Change Form - This checklist includes all materials which should be completed and submitted to EPA Region 8 when a Wyoming or Tribal Public Water System using Surface Water or GWUDISW (a Subpart H System) is making a change to treatment or building a new treatment plant.

Consumer Confidence Reports (CCR)

Form Description
Consumer Confidence Report (CCR) Certification Form for Wyoming or EPA R8 Tribal Community Water Systems Consumer Confidence Report (CCR) Certification Form for Wyoming or EPA R8 Tribal Community Water Systems - The CCR Certification Form can be used to certify that community water systems in Wyoming or on Tribal Lands in EPA Region 8 have completed and distributed their annual Consumer Confidence Report (CCR) or water quality report. Systems are required to submit this signed form to EPA Region 8 by October 1st of each year.
Consumer Confidence Report (CCR) Certification for Wyoming Community Water Systems Serving Fewer than 10,000 Persons Consumer Confidence Report (CCR) Certification for Wyoming Community Water Systems Serving Fewer than 10,000 Persons - Small community water systems in the state of Wyoming can meet their annual reporting requirements under the CCR Rule by the methods of report distribution described in this template. Systems are required to submit this signed form to EPA Region 8 by October 1st of each year.

Emergency Response Plan Templates (ERP)

Form Description
RCAP Emergency Response Plan Template for Small Community Water Systems RCAP Emergency Response Plan Template for Small Community Water Systems - Rural Community Assistance Partnership (RCAP) emergency response planning template for use by small community water systems and non-transient non-community water systems, including instructions.
Wyoming Emergency Response Plan Template for Transient Ground Water Systems Wyoming Emergency Response Plan Template for Transient Ground Water Systems - Wyoming emergency response planning template for use by transient ground water systems.
Tribal Emergency Response Plan Template for Transient Ground Water Systems Tribal Emergency Response Plan Template for Transient Ground Water Systems - Tribal emergency response planning template for use by transient ground water systems.
Wyoming Emergency Response Plan Template for Consecutive Community Water Systems Wyoming Emergency Response Plan Template for Consecutive Community Water Systems - Wyoming emergency response planning template for use by consecutive community water systems.
Tribal Emergency Response Plan Template for Consecutive Community Water Systems Tribal Emergency Response Plan Template for Consecutive Community Water Systems - Tribal emergency response planning template for use by consecutive community water systems.

Ground Water Rule (GWR)

Form Description
Ground Water Rule Sample Collection Form Ground Water Rule Sample Collection Form - Ground Water Rule (GWR) Triggered Source Monitoring Sample Collection And Reporting Form.

Lead & Copper Rule (LCR)

Form Description
Lead and Copper Tap Sample Site Plan Lead and Copper Tap Sample Site Plan - This template may be used by public water systems in Wyoming and on EPA R8 Tribal Lands to identify, verify, and certify lead and copper tap sample sites to comply with the Lead and Copper Rule.
LCR Sample Collection Form and Instructions LCR Sample Collection Form and Instructions - This template may be used as a guide instructing consumers of water provided by a public water system on how to collect samples from their home taps for the purpose of lead and copper testing.
Lead Consumer Notice of Tap Sample Results Lead Consumer Notice of Tap Sample Results - These templates may be used for public notification to consumers of water provided by a public water system, after lead and copper testing has been conducted on water collected in a consumer's home. These templates are available for results received in mg/L (ppm) or in ug/L (ppb).
Certification of Lead Consumer Notice Certification of Lead Consumer Notice - This template may be used for certification to the EPA that public notification has been sent to consumers, after lead and copper testing has been conducted on water collected in a consumer's home.
Water Quality Parameter (WQP) Report Form Water Quality Parameter (WQP) Report Form - This template may be used by water systems treating for corrosion control to report test results for Water Quality Parameter (WQP) samples.
LCR Public Education Materials for Non-Transient Non-Community (NTNC) Systems LCR Public Education Materials for Non-Transient Non-Community (NTNC) Systems - When the 90th percentile for Non-transient Non-community (NTNC) water systems exceeds the action level for lead, this template may be used to complete the required Public Education activities.
LCR Public Education Materials for Community Systems LCR Public Education Materials for Community Systems - When the 90th percentile for Community (C) water systems exceeds the action level for lead, this template may be used to complete the required Public Education activities.
LCR 90th Percentile Calculator LCR 90th Percentile Form - LCR 90th Percentile Form- Form for reporting lead and copper sample locations, location tiers, and Lead (Pb) and Copper (Cu) sample results for each monitoring period for the 90th percentile calculation.

Lead Service Line Inventory (LSLI)

Form Description
EPA Region 8 Service Line Inventory GeoSolution Opt-In Form EPA Region 8 Service Line Inventory GeoSolution Opt-In Form - This Survey123 form provides water systems an online fillable form to sign up for the EPA Service Line Inventory GeoSolution- A free GIS version of the EPA Service Line Inventory Template to utilize for their service line inventories. This option is currently only offered to water systems in Wyoming and on Tribal Lands in EPA Region 8 at this time.
EPA Region 8 Service Line Inventory Upload Submittal Form EPA Region 8 Service Line Inventory Upload Submittal Form – This Survey123 form provides water systems in Wyoming and on Tribal Lands in EPA Region 8 that do not use the EPA Service Line Inventory GeoSolution for their inventory an online repository to submit their service line inventories to EPA Region 8.
EPA Service Line Inventory Template EPA Service Line Inventory Template (xlsx) - This Excel template provides fillable forms and tables that water systems can use to develop and organize their inventory, document their methods, document how they are making the inventory publicly available, and submit the inventory to EPA.
EPA Service Line Inventory – Compliance Documentation Template

EPA Service Line Inventory – Compliance Documentation Template (PDF) - This PDF form provides fillable fields that water systems can use to document their inventory methods, disclose how they are making the inventory publicly accessible, and provide a service line inventory summary. Water systems can use and submit this template with their service line inventory to EPA if their inventory does not already include this information.
Notification of Known or Potential Service Line Containing Lead

Notification of Known or Potential Service Line Containing Lead - These documents provide templates that water systems can use for the required public education notices to all persons served at service connections with a lead, galvanized requiring replacement (GRR), or lead status unknown service lines, as required under the 2021 Lead and Copper Rule Revisions.

Maximum Residual Disinfectant Level (MRDL)

Form Description
MRDL Form 3 - Quarterly Report for Daily and Monthly Chlorine Dioxide MRDL Form 3 - Quarterly Report for Daily and Monthly Chlorine Dioxide - Quarterly Reporting Form for Daily and Monthly Chlorine Dioxide residuals.

New Public Water Systems (NEW)

Form Description
Drinking Water System Basic Information Form Drinking Water System Basic Information Form (BIF) - This form should be completed and submitted to EPA Region 8 when a water system in Wyoming or located on Tribal Lands in EPA Region 8 is being evaluated to determine if it may be serving drinking water to the public. This information may be requested from newly constructed entities, newly purchased entities or other existing entities.

Public Notification (PN)

Form Description
RTCR E-Coli Contamination Boil Water Advisory Template RTCR E-Coli Contamination Boil Water Advisory Template - In general, you must issue a boil water advisory when an RTCR Tier 1 E. coli maximum contaminant level (MCL) violation occurs. You can use this template as a guide when preparing a boil water advisory.
Loss of Pressure Boil Water Advisory Template Loss of Pressure Boil Water Advisory Template - In general, you must issue a boil water advisory when a significant loss of pressure in the distribution system occurs. You can use this template as a guide when preparing a boil water advisory for loss of pressure.
High Turbidity Boil Water Advisory Template High Turbidity Boil Water Advisory Template - In general, you must issue a boil water advisory when a high turbidity event occurs, such as a Tier 1 violation. You can use this template as a guide when preparing a boil water advisory for high turbidity situations.
Revised Total Coliform Rule - Failure To Monitor - PN Template Revised Total Coliform Rule - Failure To Monitor - PN Template - When a PWS fails to monitor for Total Coliform bacteria, it must issue a public notice to inform the consumers of its water of that failure to monitor. You can use this template as a guide to prepare that public notice.
Revised Total Coliform Rule - Failure To Report - PN Template Revised Total Coliform Rule - Failure To Report - PN Template - When a PWS fails to report their monitoring results for Total Coliform bacteria, it must issue a public notice to inform the consumers of its water of that failure to report. You can use this template as a guide to prepare that public notice.
Revised Total Coliform Rule - Failure To Perform Level 1 Assessment - PN Template Revised Total Coliform Rule - Failure To Perform Level 1 Assessment - PN Template - When a PWS fails to perform a required RTCR Level 1 Assessment, it must issue a public notice to inform the consumers of its water of that failure. You can use this template as a guide to prepare that public notice.
Revised Total Coliform Rule - Treatment Technique Violation - PN Template

Public Notification - RTCR Failure to Correct Sanitary Defect or Failure to Conduct an Assessment Violation Template - When a PWS does not complete their Level 1 or Level 2 Assessment or if they fail to complete their corrective actions within the required timeframe after a Level 1 or Level 2 Assessment, they receive a Treatment Technique Violation. Part of returning to compliance from the violation is notifying customers and consumers that they did not complete the corrections in time by issuing this public notification. It’s also a chance to inform the public of the progress you are making on the Assessment and/or sanitary defect corrections. You can use this template as a guide to prepare that public notice. This template is available in PDF and MS Word formats.
Revised Total Coliform Rule - Failure to Perform Seasonal Startup - PN Template Revised Total Coliform Rule - Failure to Perform Seasonal Startup - PN Template - When a PWS fails to perform required RTCR Seasonal Startup Procedures, it must issue a public notice to inform the consumers of its water of that failure. You can use this template as a guide to prepare that public notice.
Ground Water Rule - Boil Water Advisory - Public Notification Template Ground Water Rule - Boil Water Advisory - Public Notification Template - The Ground Water Rule specifies that a public water system must issue a Boil Water Advisory (Tier 1 Public Notification) when it has been determined that source ground water is contaminated with E. Coli bacteria. You can use this template as a guide to prepare that public notice.
Ground Water Rule - Failure to Monitor - Public Notification Template Ground Water Rule - Failure to Monitor - Public Notification Template - When a PWS fails to monitor for for a fecal indicator like E. coli bacteria within 24 hours when there is a total coliform bacteria positive sample result in the distribution system, it must issue a public notice to inform the consumers of its water of that failure to monitor.
Ground Water Rule - Failure to Take Corrective Action - Public Notification Template Ground Water Rule - Failure to Take Corrective Action - Public Notification Template - The Ground Water Rule specifies that a public water system must issue a Tier 2 Public Notification when a system fails to take corrective action for a fecal indicator positive ground water source sample or for other significant deficiencies within the required time frame.
Long Term 2 Enhanced Surface Water Treatment Rule - Failure to Take Corrective Action - Public Notification Template Long Term 2 Enhanced Surface Water Treatment Rule - Failure to Take Corrective Action - Public Notification Template - Under the Long Term 2 Enhanced Surface Water Treatment Rule a public water system must issue a Tier 2 Public Notification when a system fails to take corrective action for significant deficiencies within the required time frame.
Failure To Monitor (FTM) - Public Notification Template Failure To Monitor (FTM) - Public Notification Template - When a PWS fails to monitor for any Federally Regulated Drinking Water Contaminant, it must issue a public notice to inform the consumers of its water of that failure to monitor. You can use this template as a guide to prepare that public notice.
LCR Lead Action Level Exceedance Template LCR Lead Action Level Exceedance Template – When a PWS exceeds the lead (Pb) action level in the 90th percentile calculations, it must issue a public notice within 24 hours to inform the consumers about the potential lead impacts in their drinking water.  You can use this template as a guide to prepare that public notice.
Disinfection By-Products (DBP) Precursor Treatment Technique Template Disinfection By-Products (DBP) Precursor Treatment Technique Template - When a PWS fails to meet the required Disinfection By-Product Precursor removal percentage between the source water and the treated water it must issue a public notice to inform the consumers of its water that Total Organic Carbon (TOC) is not adequately removed and this is a treatment technique violation. You can use this template as a guide to prepare that public notice.
Haloacetic Acids (HAA5) MCL Template Haloacetic Acids (HAA5) MCL Template - When a PWS exceeds the maximum contaminant level (MCL) for Haloacetic Acids (HAA5) it must issue a public notice to inform the consumers of its water that the level of Haloacetic Acids detected in their water has exceeded the MCL set by the Federal Regulations. You can use this template as a guide to prepare that public notice.
Total Trihalomethanes (TTHM) MCL Template Total Trihalomethanes (TTHM) MCL Template - When a PWS exceeds the maximum contaminant level (MCL) for Total Trihalomethanes (TTHM) it must issue a public notice to inform the consumers of its water that the level of Total Trihalomethanes detected in their water has exceeded the MCL set by the Federal Regulations. You can use this template as a guide to prepare that public notice.
Total Trihalomethanes (TTHM) and Haloacetic Acids (HAA5) MCL Template Total Trihalomethanes (TTHM) and Haloacetic Acids (HAA5) MCL Template - When a PWS exceeds the maximum contaminant level (MCL) for both Total Trihalomethanes (TTHM) and Haloacetic Acids (HAA5) it must issue a public notice to inform the consumers of its water that the levels of Total Trihalomethanes and Haloacetic Acids detected in their water have exceeded the MCLs set by Federal Regulations. You can use this template as a guide to prepare that public notice.
Nitrate Rule - Failure To Monitor (FTM) - Public Notification Template Nitrate Rule - Failure To Monitor (FTM) - Public Notification Template - When a PWS fails to monitor for Nitrate or Nitrite contaminants, it must issue a public notice to inform the consumers of its water of that failure to monitor. You can use this template as a guide to prepare that public notice.
Nitrate Rule - Maximum Contaminant Level (MCL) – Public Notification Template Nitrate Rule - Maximum Contaminant Level (MCL) – Public Notification Template - When a PWS exceeds the Nitrate maximum contaminant level (MCL), it must issue a public notice to inform the consumers of its water that the level of Nitrates detected in their water has exceeded the MCL set by the Federal Regulations. You can use this template as a guide to prepare that public notice.

Revised Total Coliform Rule (RTCR)

Form Description
Revised Total Coliform Rule Lab Sampling Form Revised Total Coliform Rule Lab Sampling Form - This form should be completed when a water system collects any required Revised Total Coliform Rule (RTCR) samples. It should also be used when collecting “Special” non-compliance samples for the RTCR. The revised form has a column for chlorine residual, if your system adds disinfectant.
Revised Total Coliform Rule Sample Siting Plan Template Revised Total Coliform Rule Sample Siting Plan Template - This template can be used for Revised Total Coliform Rule (TCR) sample site planning. The purpose of this plan is to specify where in the distribution system routine bacteriological samples will be drawn to ensure they are representative of your system.
Revised Total Coliform Rule Seasonal Startup Checklist Revised Total Coliform Rule Seasonal Startup Checklist - Starting in 2016, this form will be required to be completed by seasonal systems PRIOR to serving water to the public. This form provides start-up procedures for drinking water systems that shut down and depressurize and are not operational year around.
Revised Total Coliform Level 1 Assessment Form Revised Total Coliform Rule Level 1 Assessment Form - This form should be completed when a water system is notified that a Level 1 Assessment has been triggered, as required under the Revised Total Coliform Rule (RTCR).
Revised Total Coliform Level 2 Assessment Form Revised Total Coliform Rule Level 2 Assessment Form - This form should be completed when a water system is notified that a Level 2 Assessment has been triggered, as required under the Revised Total Coliform Rule (RTCR).
Revised Total Coliform Rule Level 2 Assessment Sanitary Defect Correction Form Revised Total Coliform Rule Level 2 Assessment Sanitary Defect Correction Form - This form should be used when submitting corrective actions after a Level 2 Assessment was triggered.
Revised Total Coliform Rule Level 2 Assessment Sanitary Defect Correction Extension Request Revised Total Coliform Rule Level 2 Assessment Sanitary Defect Correction Extension Request - This form should be used when requesting an extension on corrective actions after a Level 2 Assessment was triggered.

Sanitary Surveys (SS)

Form Description
Wyoming Sanitary Survey Form

Wyoming Sanitary Survey Form - Sanitary survey form to be used for Wyoming ground water and/or surface water systems. This form is used to complete sanitary surveys and to ensure all information is collected or verified, and that mechanical systems, treatment process and records are reviewed as appropriate.
Tribal Sanitary Survey Form Tribal Sanitary Survey Form - Sanitary survey form to be used for Tribal ground water and/o surface water systems. This form is used to complete sanitary surveys and to ensure all information is collected or verified, and that mechanical systems, treatment process and records are reviewed as appropriate.
Significant Deficiency Correction Notice Significant Deficiency Correction Notice - This form may be used to report the correction of sanitary survey significant deficiencies identified during a sanitary survey.
Finished Water Storage Tank Inspection/Cleaning Checklist Finished Water Storage Tank Inspection/Cleaning Checklist - Fill out one checklist per storage tank & submit labeled photos of each tank component with this form.

Stage 1 DBPR - DBP Precursors (DBPP)

Form Description
DBPP Form 1 DBPP Form 1 - Total Organic Carbon (TOC) Laboratory Report Form, including instructions for completing the TOC laboratory report.
DBPP Form 3 DBPP Form 3 - Alternative Compliance Criteria Determination for Conventional Filtration Treatment Plants, including instructions for completing this form.
DBPP Form 4.4.5 DBPP Form 4.4.5 - Enhanced Coagulation Compliance Determination for Conventional Filtration Treatment Plants, including instructions for completing this form. This form will compute the RAAs, actual TOC removal percentage, TOC removal ratios and the running annual average of the TOC removal ratios for enhanced coagulation compliance.

Stage 1 DBPR - Bromate and Chlorine Dioxide (BRCL)

Form Description
Bromate Running Annual Average (RAA) Form Bromate Running Annual Average (RAA) Form - The Bromate Running Annual Average Reporting Form for drinking water systems using ozone treatment processes.
Chlorine Dioxide Maximum Disinfectant Residual Level (MRDL) Form Chlorine Dioxide Maximum Disinfectant Residual Level (MRDL) Form - The Chlorine Dioxide Daily Residual Measurement Reporting Form for drinking water systems using chlorine dioxide treatment processes.
Chlorite DBPR Daily Measurement Form Chlorite DBPR Daily Measurement Form - The Chlorite Disinfectant Byproduct (DBP) Reporting Form for drinking water systems using chlorine dioxide treatment processes.

Stage 2 Disinfectants/Disinfection By-Products Rule

Form Description
Stage 2 DBPR Compliance Monitoring Plan Template Stage 2 DBPR Compliance Monitoring Plan Template - Stage 2 DBPR Compliance Monitoring Plan Template For Public Water Supply Systems, including instructions and addendums.
Stage 2 DBPR LRAA OEL Form Stage 2 DBPR LRAA OEL Form - Stage 2 DBPR Reporting Form for Locational Running Annual Averages (LRAA) and Operational Evaluation Levels (OEL) for Total Trihalomethanes (TTHM) and Haloacetic Acids (HAA5), including instructions for completing this form.
Stage 2 DBPR Operational Evaluation Report Stage 2 DBPR Operational Evaluation Report - The Stage 2 DBPR Operational Evaluation Report (OER) must be completed and sent to EPA Region 8 no later than 90 days after being notified of analytical results that indicate an operational evaluation level has been exceeded. The operational evaluation report forms are tailored for systems with surface water, ground water, or consecutive system sources.

Surface Water Treatment Rules (SWTR)

Form Description
IESWTR Form for Conventional or Direct Filtration ≥ 10K IESWTR Form for Conventional or Direct Filtration ≥ 10K - Use this form for systems using conventional or direct filtration and serving populations of at least 10,000 people. The IESWTR monthly report for turbidity and disinfection data contains the Daily Data Sheet for Combined Filter Effluent (CFE) Turbidity, Disinfectant Residual Data, and Individual Filter (IF) Turbidity Monitoring data.
LT1SWTR Form for Conventional or Direct Filtration < 10K LT1SWTR Form for Conventional or Direct Filtration < 10K - Use this form for systems using conventional or direct filtration and serving populations of less than 10,000 people. The LT1SWTR monthly report for turbidity and disinfection data contains the Daily Data Sheet for Combined Filter Effluent (CFE) Turbidity, Disinfectant Residual Data, and Individual Filter (IF) Turbidity Monitoring data.
SWTR Fact Sheet SWTR Fact Sheet - A summary of the requirements for filtered public water systems under the: Surface Water Treatment Rule (SWTR); Filter Backwash Recycling Rule; Interim Enhanced SWTR (IESWTR); Long Term 1 Enhanced SWTR (LT1ESWTR); and Long Term 2 Enhanced SWTR (LT2).
SWTR Policy #5 SWTR Policy #5 - Location(s) for Measurement of Filtered Water Turbidity. This policy provides the criteria by which EPA Region 8 determines whether filtered water turbidity is being measured in the appropriate location(s) for determining compliance with the Surface Water Treatment Rules.

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Last updated on October 31, 2024