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"' "" Commonwealth of Massachusetts
C` Executive Office of Energy &Environmental Affairs
LlDepartment of Environmental Protection
Southeast Regional Office•20 Riverside Drive, Lakeville MA 02347.508-946.2700
DEVAL L.PATRICK MAEVE VALLELY BARTLETT
Governor
Secretary
DAVID W.CASH
Commissioner
September 24,2014
Nina Coleman RE: BARNSTABLE—Public Water Supply
Marine&Environntental Affairs Division Sandy Neck Beach
1189 Phinney's Lane PWS ID}#:4020023
Centerville,MA 02632 Sanitary Survey
Dear Ms.Coleman:
Please find attached the following information:
Sanitary Survey Report for a survey perforried at Sandy Neck Beach,Barnstable,MA on June 24,2014,
Please note that the signature on this cover letter indicates formal issuance of the attached document.
If you have any questions regarding this document,please contact Isabel Collins at 508-946-2726 or
Isabel-ColIins@state.ina.us.
Sincer '
Richard J. Rondeau,Chief
Drinking Water Program
Bureau of Resource Protection
R/IC
I
ecc: Certified Operator: Roy Maher RMaher@Rhwhite.com
i
Barnstable Board of Health
Barnstable Building Ilspector
Barnstable Planning Board
Y:\DWP Arch ive\SERO\Barn stab le-4020023-Sanitary Surveys-2014-09.24
i
P:\SS\SS2014\Barnstable-4020023
- ,90 •01 i1ti, 7 ti as 6toL
"i 11 i
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This Information is available In alternate format call Michelle Waters-Ekanem,Diversity Director,at 617.292.5751.TDD#1-866.539.7622 or 1-617-674.6868 !
I
MesaDEP Website:%wm.mass.govldep
Printed on Recycled Paper
Sandy neck Beach Barnstable
4020023 June 24,2014
Public Water System
Sanitary Survey
CITY: Barnstable
MID: .4020023
M NAME: Sandy Neck Beach
Survey Date: June 24, 2014 Report Date: September 24, 2014
Surveyor: Isabel Collins Affiliation: DEP
Person Interviewed: Roy Maher Title: Certified Operator
Person Interviewed: Title:
PUBLIC WATER SUPPLIERS:
Attached is a Sanitary Survey Report for the above referenced Sanitary survey site visit.
At the end of the report is a Water System Compliance Plan which consists of the following
(checked items only):
❑ Table A - Summary of violations and Notice of Noncompliance (if violations were
observed during the survey)
® Table B--Summary of deficiencies and required corrective actions
❑ Table C—Recommendations
® Water supplier response and certification.
Within 30 days of receipt of this inspection report, you must complete and
submit the response form if your system has TABLE A—Violations and/or
TABLE B-Deficiencies. Attach a copy of each completed table listing the
date that the corrective action was or will be taken by your system and all
other applicable documentation. (310 CMR 22.04(12))
2
Sandy Neck Beach Barnstable
4020023 June 24,2014
SYSTEM DESCRIPTION:
Sandy Neck Beach is a transient non-community water system. It consists of a 6-inch
steel cased well located at the southern end of the Beach Parking Lot under a lookout
deck. The well serves the Beach Area Snack Bar/Bathhouse and Ranger Station. The
water is not treated.
A ,complete rehabilitation of the water system's major components was completed on
April 4, 2011. During the summer of 2014, a deck was built around the wellhead and a
permanent wooden box/bench was placed over the wellhead.
The water system is considered a grandfathered non-conforming water supply system
as the site does not provide wellhead protection as parking is allowed within the Zone 1
of the well.
ADMINISTRATION:
General System Information Is this correct? Yes N No ❑
rp
a $�y` _;.'. -r ':�v,y F:ayrg,S',•
w s r r r t $e�So11 l'Op Stats uv a C t £ L y Y cs Fx2
'.y.. ,� 5 2•, 4kx .�c}ar di. ,-. -
s I'o'ulation>;
x
`r� �PWS: Season Seasons = pp i 4M
(wJnter� � � �
(t£'a;
<cw, r '••t t_ e a sG° 7 a xe'rr-s:. .ssn ,k.. YkQit �a:
�.Xy>r �""�'�,'... .... ...._ r e r .: ..-� �r r fi^r F _ n °z.•�--•.•.at rm�4 i���'�'�:'�"r-.r�-•2a
E 20023 NC 101 1231 3001 261 21 1
Facility Address: Is this cor ect9 Yes N No ❑
f r f ,< € ,�}PINS Facllft Address
.+r'"",R'xr �M 1Y x ' AS
N
P X
•S,*GX Y�iF�� 1 F/}S cyI/ A EST `•txS�Y����
,:_ .,.,._v .:.:, x...,,.a. the(L�._i4� :.�.r c..�T..� .....,.�_`" r}.`-...•.���`Y�:n�T•e'� ,.If.-.7 rs c.�K°f3L., r �wt-�--s�.. � .e�✓ir r -u��F#R�Y>
SANDY 590 6680000 rnna.coleman@lown.barnstable.ma.us (508) (508)
NECK SANDY BARNSTABLE 362-8300 362-
BEACH NECK RD 6517
Mailing Address: Is this correct? Yes ® No ❑
z �� P1AlyS Mailing�dd �ss �,;, rgig�
MARINE&ENVIRONMENTAL AFFAIRS 11189 PHINNEY'S TTN:NINA CENTERVILLE MA 026320000
jDIVISION_ LANE COLEMAN
Contact Information
_„ ,;
.rxc.r.. - . ,,-•.. _.... -.....:_.Y::-•rs:
Is this correct? Yes ® No ❑
T, _ fin; a F »,�s FF rb a
tz:s, r o . .'�.
G f �PtN3 G,nalrrformatlon�
:zrt ,..,:u:F,.,ari��.5�'"'�-x�.?�'� �'r}z'...7>n`�l�✓2 3.._`41U .,sx ��, �y-""e,�qa ` t� 7,, y �, l�� rC. �y .i�'x r,,. -�c.��."cw +" .�^ I
s,����F-:1� x>�„ � �� � 5 Asid$�ess� ` � x�2� � ���'oWrt � S3atg :��Zip,� ���{�•��p _;-
.3 rz._a..,..�U.1 ..:..,,+^�� ::%c;_�. .ra...�°ws,...;: ..:.....i L �v S .? s � ^a =}...'.c •s:fix°•>'r "' t103" P .}gyp q +�4020023 NINA COLEMAN MARINE& 1189 CENTERVILL MA 026320000 5083628300 Y
ENVIRONMENTAL PHINNEY'S E
HAIRS LANE
Comments:
None.
3
Sandy Neck Bench Barnstable
4020023 June 24,2014
Certified Operator Informations Is this correct? Yes ® No ❑
x F
tit.vw,, .y..r`T"` ^� ..34�' F-':
ima�ryu0pera�ora��x.�iv.< �'�.: sa`
P : Q#Fls ICIL; s `?Ac4ess Adtxessfj ) "Tulrv`� Skate Zfp 1Nr Phan ,bite
14020023 ROY MAHER PO'BOX 290 JEAST WAREHAM IMA. J02538 8883777678 5083629881
:: ♦ r E#3 �'1:�St f t 6 ,i - � s "4 -
PWSfp# �1r { t sty Pblttan Ltcsris Grade ,si.) gpsel �iny=�Qperto
i4020023 RUSSELL E TIERNEY JOW OPERATOR 3T/4D 11240717894 IN
i4020023 ICHRIS I IGARVIN OW OPERATOR 1T OI 24287
i4020023 IROY JA IMAHERJ9W OPERATOR 3D/3T 23650/23819/23900 IY
`� S ste t�tbutlorrCtass N
P1A1$fD#� ytion CIasS Popu`Jatlo�t Seru��;
,4020023 VSS 300
Does the PWS have a certified operator? (Verify that primary operator listed Yes ® No ❑
in WQTS is correct PWS operator).
Are operator grades appropriate for system size and/or treatment type? Yes ® No ❑
Does the system have the correct staffing levels for the system size and grade? Yes ® No ❑
Is certified operator or a backup operator available for emergencies? Yes ® No ❑
Comments:
None
OPERATION AND MAINTENANCE:
Is there an adequate spare pants inventory? Yes ® No ❑
Is there an 0&M Manual? Yes ® No ❑
Is there a preventative maintenance program? Yes ® No ❑
Are operational records collected appropriately? Yes ® No ❑
Are records properly maintained and available for review? Yes ® No ❑
Frequency of master meter readings? Daily ❑ Monthly® Other
Frequency of distribution meter readings N/A
How frequently are meters calibrated? New meters
• The Department recommends that source meters be calibrated on an annual basis.
Are emergency telephone numbers posted? Yes ® No ❑ I
Is all critical infrastructure locked?
Yes ® No ❑
Does the PWS have available an emergency response plan prepared in
accordance with the provisions of 310 CMR 22.04(13)? Yes ® No ❑
4
Sandy beck Beach Barnstable
4020023 June 24,2014
Who performs emergency repairs.
(Systems without dedicated staff) Contractor
Comments:
Separate water meters were installed on the service lines to the guard shack and the
bathrooms.
TREATMENT - GENERAL:
Treatment listed Unapproved treatment
No Treatment ® above is correct ❑ installed ❑
• Unapproved treatment is subject to MassDEP permit requirements
If a sediment filter is being utilized how often is the filter replaced? N/A
For sources without permanent disinfection: Is an emergency
chemical injection port available? Yes® No ❑ N/A❑
Are theme any unprotected bypasses in the treatment process that
could result in contamination of finished water? Yes ❑ No❑ N/A
Is information from the manufacturer available for reference? Yes ❑ No ❑ N/A
Is chemical storage, containment,and safety equipment adequate? Yes ❑ No ❑ N/A N
Is equipment properly maintained? Yes ❑ No ❑ N/A N
Are alarms tested and adequate? Yes ❑ No ❑ N/A N
Are chemical treatment forms submitted monthly as required? Yes ❑ No ❑ MAN
Are they completed properly? Yes ❑ No ❑ N/A N
Is operator familiar with the treatment system and its operation? Yes❑ No ❑ N/A N
Is the treatment system providing 4-hog inactivation treatment? Yes❑ No ❑ N/A
Has the system experienced a loss of membrane integrity? Yes❑ No ❑ MAN
Comments:
PWS not required to provide 4-Log inactivation treatment
I
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5
i
Sandy Neck Beach Barnstable
402OD23 June 24,2014
SAMPLING:
[ o of tacteria�ainples £ Fre uency 3 Ate ''�yL�'`��,� .� .�,
I YYRUN,
1�7
,,.. _�, ._'.,�,a .�Summer),ry .Y-u�.:_� _:._..w�Sumr►Ierl._._..� . r...._�.��(�i���ir��.,:�.. �-k���.�-X��;��1!�tt�e��-.,..
i40200231 2 QUARTER 1 QUARTER
Does the system have an approved Total Coliform Sampling Plan? Yes ® No ❑
Have changes been made to the system(population,configuration,
storage tanks, etc.)such that the coliform sample plan does not comply
with 310 CMR 22.05? Yes ❑ No
Is the system taking the correct number of bacteria samples? Yes ® No ❑
Is the system using appropriate coliform sample sites? Yes No ❑
Is the system using appropriate source sample sites? Yes ® No ❑
Are raw water sample taps available for all sources? Yes ® No ❑
Comments:
Submit update d TCR plan, See Table B for comments.
STORAGE:
Maintenance and Condition
PIIVS,�D� .�,Sto sTankNam@ j =storage x Tank Cap,�city 1'astinsp@ctlo�i�i �astr;l@ane�dt, s rir tU��)�i�'1� - -
-
;40202003 ITank 1 BLADDER STEEL 30 INSTALLED 2011 N/A EXCELLENT
o MassDEP recommends storage tanks be inspected and cleaned every 5 years.
Protection and Safety
IZi�I �n(�`
Y 9.;•. �, w� .s�'1�� �xks .0-
.� Rropg�t� C,Ov@r@�f �F , YM S PxAtec a try a
P1�StQ����OFtA¢E>TAN1C 1J�►M��f�var(fov�c Y �4 and x f �Ye�t�dgr� .,Sample,���.av��,,� a1
. .�_...y �7. � r"Y - S, z "�-t"�' s.! h k r� Sar@Qned?(4) 3.'�a�i?�}.CQr�trQ�~i F=%3-•t.!'e.At„ �+Yt, �+� ..
2.-,.',�!=' .�. .:CF -.4_v. .l..c.._: .......M1:.�Y• .:,+'C:!:�.. f -'Yt.�. :tCw....: z1 T-.~..;.�.�F'. „-..4s_�: r.Alar►iaa?_ _ �--z�3...=.,�`� �.�s� ,,_. .. .. ,. , ....:a. I
4020023 TANK 1 INSIDE
N/A Y NIA Y N/A N Y
BUILDING_ �
The storage tanks have nearby injection ports to allow emergency disinfection. Yes
g Y � J p ❑ No I
The storage tanks are adequately protected against vandalism, Yes ® Na❑ j
(')Are there any holes or failures in the tank roof or structure? Yes ❑ No
(2)Have any tanks been identified as subject to flooding or run-off? Yes❑ No
(')Are all the tanks protected from unauthorized entry? Yes ® No❑
(4)Is proper screening in place on all overflow pipes and vents? N/A® Yes ❑ No ❑
Comments:
There is an injection port on the line feeding the guard shack, also there are two spigots
that could be removed and retrofitted as injection ports. j
6
i
Sandy Neck Beach Barnstable
4020023 June 24,2014
PUMPING STATIONS:
�y..c'xs'ror 3r—rs ?r?s F A�
3 s Y F�, ptng Statipns
.. _..- ..,s<.a... ............. > _...... :..... u„..s_.k . ..[:..:-,._..�5,_..;n ems. .:.�•c.-.....,z4:..�.,_..'C..�F'.
=P1i11S11?�dump�S#t Name.#pf PG�p&t;ac_a.�o�`'Avatf°W�tet��fypa GP1VE Erfie�g�P4Y+[er?�JoY��HR�II��'ot.TYRe
14020023 PUMP#1 1 CTIVE IRAW I INI 5 SUB
Are all pump stations recorded in WQTS? Yes ® No❑
Is there flooding or standing water in the pump house? Yes ❑ No
Does the air/water relief valve discharge have an air gap? Yes ® No❑
Are there any open floor drains in the facility? Yes ❑ No
Are pump stations adequately maintained? Yes ® No❑
Comments:
A new pressure gauge, wellhead, constant pressure well controller and pressure tank
were installed in 2011.
DISTRIBUTION/TRANSMISSION
Has the system submitted a distribution map to MassDEP Yes ❑ No
Are valve locations known or identified? Yes ® No ❑
How many distribution systems are there? 1
Is adequate pressure being maintained?(20-60 psi) Yes ® No ❑
.... . -._I Guard
The distribution system has 1 dead ends which are flushed Shack
List distribution system weaknesses or problems None
Date of last leak detection survey: Daily Percent of system surveyed?: 100%
Are distribution valves exercised regularly? Yes ❑ Frequency? No
Is there a hydrant maintenance program? N/A ® Yes ❑ No ❑
Is there an adequate flushing program? N/A ® Yes ❑ No ❑
The Department recommends that the distribution system be flushed tvice a year.
Comments:
None.
7
Sandy Neck Beach Barnstable
4020023 June 24,2014
CROSS-CONNECTIONS /BACKFLOW PREVENTION:
R1M1��Ipj)r�faoes_�5.stem�.Have A._proxQd�rQ,ssuCgnneefiontPlatt4 Was.:�X e6jtn,�;�ruey_�v_nd��tet`?,
�4020023 Y Y
NTNC& TNC only:
Was a cross-connection survey conducted by a Massachusetts Yes ® No ❑ N/A ❑
Certified Cross-connection Surveyor?
Surveyor Name: John Aprea
Surveyor Certification M
Date of last system-wide survey 12-28-06
Did the cross-connection survey reveal any unprotected cross- Yes ® No ❑ NIA ❑
connections)?If yes,have all cross-connections been eliminated
or properly protected?Yes®No ❑
Have testable backflow prevention devices, if present,been N/A
tested in accordance with the frequency stated in 310 CMR Yes El No ❑
22.22(14)(d)?
Are there Hose Bib vacuum breakers on all threaded faucets? Yes ® No ❑ NIA ❑
Comments:
r
e Hose Bibs are equipped with atmospheric vacuum breakers (AVBs). Cction Control Plan Approved by DEP on 7/3/07.
SOURCES:
.....::i.Y<....L..:,...._y.._..nib....cv.......,..W.itH_.:...2'.i:!::.=:.^:wa.a3'.:'r....__- --Rxa
�Q�fsum'
.� .t ,a'er',c.•C 2i,,,.,. x ,_c;z
"< -i� r��...i. .`s Q�0 ��,/oPurclt'� % w -'P✓oPurch �2 ' 1�f�Q��� }��r y�si~4. � -`s#i'-,:���'�z���.,`rr � �
PW$fR �ouroas t 3 YEARME
K.X .
,,�� � -_ GroWncl GrduOd SfJ�E�4+�i�S►�rtace �..� t3�fna d ��,��C?aiLyDama d�� G )��-.,�-�.r«
_
14020023 1 100 0 0 0 2013 0.05 0.00041643835616438356164 0.002
Groundwater Sources:
Well Construction Informat
ion Is this correct? Yes ® No ❑
r.s �."qx �y2��� 1U -". � 'a'` 35 - C•as_My_'-- y1F'.'r F�'e.,-`i xTr•r:�r R'�yi:�x. #t'w- � .;+--m•,`�.
s``" �" " ..Lx 1-k, ✓\ r ;.t,. —wa. ,
SQS1�.�_D Soutca,t�lalne Yy _:.xLccatigp�_; _ Sg4 4'�?�ntR.!
i4020023-OIGIWELL 1 JOFF SANDY NECK ROAD ISGWNP JACTIVE GP O 0
Well Inspection
nz .k r Ic p W--S t}^v n Qs fT r' 1c,./rfy�(� �+ r. y
3 �rivC.tiFt -1` 1 R� A. + f77pI eVl��f�7. ^a.9 +,y'f' { .IMOMMJ 'LMIN
4--
:� Qua a ip a oo hate Gasing ftelg f(ftj In pIE{YIN}? _Well Housg?, 1�erat Screenesl2 Seasgnal?G+ondltton
14020023-01G 1 6/30/20061 2 N UNDER DECK Y N RUSTED
8
Sandy heck Beach Barnstable
4020023 June 24,2014
Are all wells in use approved and recorded in WQTS? Yes ® No ❑
Are all of the wells listed on the sampling schedule? Yes ® No ❑
Are manifolded wells reflected accurately on the schedule? Yes ❑ No ❑ NIA
*Is the wellhead damaged in a manner that would make the source
susceptible to contamination Yes ❑ No
*Are there unprotected openings in the well cap or casing? Yes ❑ No
*Is the wellhead; cap, and/or vent subject to flooding? Yes ❑ No
Are all wells> 100 ft from the nearest surface water?(uc sys(en►s) Yes ® No ❑
Is the quantity of water supply adequate? Yes Z No ❑
Do any sources run dry? Yes ❑ No
If yes, during which periods and how is it handled?
Comments:
None
Source Protection:
SWAP Database Information
:.._.._.... . .. .w w..._...,.. i*
xt
oaiclD `A�provedvotumel z4��1,iIUVP1ong`ipfrminafl4n a ]stiaY Poll i nfirc �
1 ! no $
.
I4020023-01G 0106 500 1979CHART Y BUILDINGS,ROADWAYS,
PPARKING AREAS
Is there excessive use of fertilizers or chemicals in Zone I? Yes ❑ No
Are there any known or potential, sources of pollution observed in the
Zone I or IWPA (other than those listed above)? Yes ❑ No
Is there an awareness of threats and an attempt to minimize them? Yes No ❑
Is protection area posted? Yes ❑ No
Are source water protection measures adequate? Yes No ❑ `�
i
Comments:
None ,
OTHER ISSUES OBSERVED:
I
None
9
Sandy Neck Beach Barnstable
4020023 June 24,2014
Statement of Zone I Compliance
[]Your system is currently in compliance with Zone I requirements for the following well(s):
Please be advised that any modifications to the Zone I or activities within are subject to DEP
approval.
NPlease note that),oil lack ownership or control of the,required 100 ft Zone I protective radius around
the following well(s): 4020023-01G if you plan to modify or expand this source or to replace any
wells, you must notify DEP (in accordance with 310 CMR 22.21(3)(b), 310 CMR 22.04(1) and
22.21(10)(a)). At the time of such notification of a proposed modification or expansion, DEP may
require you to comply with the Zone I requirement.
NYou are hereby notified that the following well(s): 4020023-01G are in non-conformance with the
MassDEP's requirement(310 CMR 22.21(1)(b)(5)) that Zone I activities be limited to those directly
related to the provision of public water or will have no significant adverse impact on water quality
(as specified`in Policy 94-03A). To the extent possible,efforts should be made to reduce or eliminate
the impacts of non-conforming uses within the Zone L Pursuant to 310 CMR 22.04(l)and 22.21(a),
you must notify the DEP if you plan to modify or expand your source or to replace any wells. At the
time of such notification of a proposed modification, expansion, or replacement, DEP may require
you to comply with the Zone I requirement that all Zone I activities be limited to those directly
related to water supply or will have no significant impact on water quality..
Non-Conforming activities documented within the Zone I: BUILDINGS,ROADWAYS,PARKING AREAS
PRIOR OUTSTANDING ACTIONS
Enforcement Actions
NONE
Inspection Actions
NONE
I �
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10
Sandy Neck[teach Barnstable
4020023 June 24,2014
SUMMARY OF FINDINGS
Table A—Violations -None
Please note that this document is also a Notice of Noncompliance(NON)pursuant to M.G.L.c.21A,§16 and 310
C.M.R.5.00. Within 30 days of receipt of the NON and inspection report,you must fill-in the corrected date(s)and
submit this form to MassDEP and the attached SANITARY SURVEY COMPLIANCE PLAN RESPONSE FORM, i
including all applicable attachments.If the time required to complete the correction is greater than 3 months,submit
quarterly progress reports and provide an anticipated completion date.
GIVR T/F/M. .. : i q ` "-D Date.
C lahon. TABLE A-CORR>CTtVE ACTION- SignifFaiit ComPtete by
Date..
Deticicne * P.WS
1.
Table B—Deficiencies
MassDEP has made note of several items that do not reflect good water system practice and, if left unresolved,could lead to
problems that are more serious.Some of these items may be potential violations,and are summarized below.Due to the item's
severity or importance MassDEP has included a required course of action with a compliance date.
T/F/M Citation TABLC B-CORRECTIVE ACTION Sig ifi att A Con ple a by.
D cftDo te:
- eficieitc
1. T 310CMR22.05 Submit updated Coliform Sampling Plan and Map of the N October
Distribution System to the attention of Isabel Collins,Mass DEP, 28,2014
Southeast Regional Office,20 Riverside Dr.Lakeville,MA 02347.
Attached are form and instructions.
Table C—Recommendations-None
MassDEP has made note of items with a recommended course of action,summarized in Table C.it is strongly encouraged to
follow the recommended actions in order to improve ability to provide a safe supply of drinking water.Failure to do so could
eventually lead to violations of the regulations.
T/Fm1
:... . TABLE C-RECOMMENDATIONS _. .. :... -:.:.........:.::._..........,.:_.:::>.._,_:.. .
1.
*Groundwater Rule Significant Deficiencies: The EPA, as part of the Groundwater Rule,required states to identify
specific Significant Deficiencies that are related to the potential for fecal contamination of the water system. Significant I
deficiencies, when identified at a PWS that is subject to the Groundwater Rule, are regulated under the treatment f
technique requirements of the G WR. A PWS has 120 days to correct any significant deficiencies after notification from
the state of their existence. If the deficiencies cannot be corrected within 90 days, then the PWS must enter into a
MassDEP-approved correction action plan, with intermediate timelines for compliance. Failure to have an approved
corrective action plan in place within 120 days or to comply with the timelines contained within the corrective action
plan, constitutes a treatment technique violation, as detailed in 310 CMR 22.26(4). 1f a system fails to correct any
identified significant deficiencies, then the PWS will be required to provide an alternate source of water, eliminate the
source of contamination,or provide treatment that reliably achieves at least 4-log inactivation of viruses.
i
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11
Sandy Neck Beach Barnstable
4020023 June 24,2014
SANITARY SURVEY COMPLIANCE PLAN
RESPONSE FORM for TABLE A & B
Within 30 clays of receipt of this inspection report,you must complete and submit this response form if your
system has TABLE A Violations and/or TABLE B-Deficiencies. Attacli a copy of the completed tables listing
the date that the corrective action was or will be taken by your system and all other applicable documentation.
(310 CMR 22.04(12))
Please note that violations listed in TABLE A of the Compliance Plan are also a Notice of Noncompliance
(NON) pursuant to-M.G.L. c.21 A, §16 and 310 C.M.R. 5.00 and may require the submission of quarterly
written progress reports on the identified violations.
The following corrective actions listed in the Sanitary Survey Compliance Plan(s)TABLE A and/or B lias been
taken by the public water system.(Please check all that apply).
>lY).
l
❑ My system has taken ALL of the corrective actions listed within the timeframes specified in the Sanitary
Survey Compliance Plan(s).
• For each item,I have listed the completion date of the corrective action within each table.
• I have attached copies of supporting documentation as required.
❑ My system has taken SOME BUT NOT ALL of the corrective actions listed within the timeframes
specified in the Sanitary Survey Compliance Plan(s). My system HAS NOT complied with ALL of the
requirements set forth in the Sanitary Survey Compliance Plan(s).
• For each item, I have listed the actual or anticipated completion date of the corrective action within
each table.
• I have attached copies of supporting documentation as required.
• 1 have attached a revised corrective action schedule establishing timelines for my system to address
outstanding items and I will submit a written progress report each quarter(every 3 months)until all
items have been addressed, at which time written documentation of completion shall be submitted
to the Department. I understand that my system may be subject to further enforcement action.
❑ My system is UNABLE to comply with some or all of the corrective actions within the timeframes
specified in the Sanitary Survey Compliance Plans ..l understand that il
ly y system may be subject to
further enforcement action.
• An explanation is attached.
i hereby acknowledge receipt of the inspection findings and compliance plan table(s)of the sanitary survey conducted
by the Department of Environmental Protection's Drinking Water Program. I certify that under penalty of law I am
the person authorized to fill out this form and the information contained herein is true, accurate and complete to the
best of my knowledge and belief.
Water Commissioner,Owner,Owner Representative or Other Responsible Party:
Signature: Date:
Print Name:
Title:
i
Return this form,a copy of each Compliance Plan Table and all attachments to: j
DEP-BRP Drinking Water Program,20 Riverside Drive,Lakeville,MA 02347
Attn:Isabel Collins
12