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

Reporting Forms

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
Wyoming System Change Form Wyoming System Change Form - This form should be completed and submitted to EPA Region 8 when a Public Water System in Wyoming is making changes to any source, treatment, water system facility (WSF), or management. The form is also available in MS Word format.
Tribal System Change Form Tribal System Change Form - This form should be completed and submitted to EPA Region 8 when a Tribal Public Water System is making changes to any source, treatment, water system facility (WSF), or management. The form is also available in MS Word format.
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. The form is also available in MS Word format.
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. The form is also available in MS Word format.
GWUDISW Form GWUDISW Form - The Ground Water Under Direct Influence of Surface Water Assessment form should be completed and submitted to EPA Region 8 when a Public Water System is making any changes to a ground water source. The form is also available in MS Word format.

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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. The form is also available in MS Word format.
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. The form is also available in MS Word format.

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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. This form is also available in MS Word format.
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. This form is also available in MS Word format.
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. This form is also available in MS Word format.
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. This form is also available in MS Word format.
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. This form is also available in MS Word format.

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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. This form is also available in MS Word format.

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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. This template is also available in MS Word format. These Lead and Copper Tap Sample Site Plan Instructions may be used as a guide for how to properly complete lead and copper tap sample site plans.
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. This template is also available in MS Word format.
LCR Consumer Notification Form - Notice of Lead Tap Water Results LCR Consumer Notification Form - Notice of Lead Tap Water Results - This template 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. This template is also available in MS Word format.
LCR Consumer Notice Certification Form LCR Consumer Notice Certification Form - 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. This template is also available in MS Word format.
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. This template is also available in MS Word format.
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. This template is also available in MS Word format.
LCR Public Education Materials for Community Systems serving more than 3300 LCR Public Education Materials for Community Systems serving more than 3300 - When the 90th percentile for Community (C) water systems (population > 3,300) exceeds the action level for lead, this template may be used to complete the required Public Education activities. This template is also available in MS Word format.
LCR Public Education Materials for Community Systems serving less than 3300 LCR Public Education Materials for Community Systems serving less than 3300 - When the 90th percentile for Community (C) water systems (population < 3,300) exceeds the action level for lead, this template may be used to complete the required Public Education activities. This template is also available in MS Word format.
LCR 90th Percentile Calculator LCR 90th Percentile Calculator - This MS Excel spreadsheet can be used to calculate 90th Percentile values used to determine the action levels for both Lead (Pb) and Copper (Cu) by the linear interpolation method.

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Maximum Residual Disinfectant Level (MRDL)

Form Description
MRDL Form 1 - Chlorine and Chloramines MRDL Monthly Worksheet MRDL Form 1 - Chlorine and Chloramines MRDL Monthly Worksheet - Worksheet for calculating monthly chlorine and chloramines residual averages. The results obtained can be used later to complete MRDL Form 2. This template (MRDL Form 1) is also available in MS Word format.
MRDL Form 2 - Chlorine and Chloramines MRDL Running Annual Average (RAA) MRDL Form 2 - Chlorine and Chloramines MRDL Running Annual Average (RAA) - Quarterly Reporting Form for Chlorine and Chloramines Maximum Residual Disinfectant Level Running Annual Average (RAA). This Form is also available in MS Excel format as well as MS Word format.
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. This template is also available in MS Word format.

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New Public Water Systems (NEW)

Form Description
Wyoming Drinking Water System Basic Information Form Wyoming Drinking Water System Basic Information Form (BIF) - This form should be completed and submitted to EPA Region 8 when a water system in Wyoming is being evaluated to determine if it may be serving drinking water to the public as a brand new entity or a newly purchased entity. This form is also available in MS Word format.
Tribal Drinking Water System Basic Information Form Tribal Drinking Water System Basic Information Form (BIF) - This form should be completed and submitted to EPA Region 8 when a water system located on Tribal Lands in EPA Region 8 is being evaluated to determine if it may be serving drinking water to the public as a brand new entity or a newly purchased entity. This form is also available in MS Word format.

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Public Notification (PN)

Form Description
E-Coli Contamination Boil Water Advisory Template E-Coli Contamination Boil Water Advisory Template - In general, you must issue a boil water advisory when a Tier 1 E. coli maximum contaminant level (MCL) occurs. You can use this template as a guide when preparing a boil water advisory. This template is also available in MS Word format.
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. This template is also available in MS Word format.
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. This template is also available in MS Word format.
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. This template is also available in MS Word format.
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. This template is also available in MS Word format.
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. This template is also available in MS Word format.
Revised Total Coliform Rule - Treatment Technique Violation - PN Template Revised Total Coliform Rule - Treatment Technique Violation - PN Template - When a PWS does not complete their corrective action 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. You can use this template as a guide to prepare that public notice. This template is also available in MS Word format.
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. This template is also available in MS Word format.
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. This template is also available in MS Word format.
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. This template is also available in MS Word format.
Haloacetic Acids (HAA5) MCL Template Haloacetic Acids (HAA5) MCL Template - When a PWS exceedes 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. This template is also available in MS Word format.
Total Trihalomethanes (TTHM) MCL Template Total Trihalomethanes (TTHM) MCL Template - When a PWS exceedes 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. This template is also available in MS Word format.
Total Trihalomethanes (TTHM) and Haloacetic Acids (HAA5) MCL Template Total Trihalomethanes (TTHM) and Haloacetic Acids (HAA5) MCL Template - When a PWS exceedes 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. This template is also available in MS Word format.

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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. This template is also available in MS Word format.
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. This template is also available in MS Word format.
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. This template is also available in MS Word format.
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). This template is also available in MS Word format.
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). This template is also available in MS Word format.

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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. This template is also available in MS Word format.

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. This template is also available in MS Word format.
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. This template is also available in MS Word format.
Storage Tank‐ Above Ground Rooftop Component Checklist for Finished Water Tanks Storage Tank‐ Above Ground Rooftop Component Checklist for Finished Water Tanks - Fill out one checklist per storage tank & submit labeled photos of each tank component the sanitary surveyor was unable to access and completely evaluate with this form. There are two versions of this form. Both are available in MS Word Format. Wyoming MS Word format  and  Tribal MS Word format
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. There are two versions of this form. Both are available in MS Word Format. Wyoming MS Word format and Tribal MS Word format

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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 2 DBPP Form 2 - Alternative Compliance Criteria Determination for Conventional Filtration Treatment Plants, including instructions for completing the form. DBPP Form 2 is also available in MS Excel format. This form will compute the RAAs for you. DBPP Form 2 Instructions contains instructions for completing the Excel version of DBPP Form 2.
DBPP Form 3 DBPP Form 3 - Alternative Compliance Criteria Determination for Conventional Filtration Treatment Plants, including instructions for completing this form.
DBPP Form 4 DBPP Form 4 - Enhanced Coagulation Compliance Determination for Conventional Filtration Treatment Plants, including instructions for completing this form. This form is also available in MS Excel format. 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. DBPP Form 4 Instructions contains instructions for completing the Excel version of DBPP Form 4.

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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. This form is also available in MS Word format.
Stage 2 DBPR LRAA Form Stage 2 DBPR LRAA Form - Stage 2 DBPR Reporting Form for Locational Running Annual Average (LRAA) for Total Trihalomethanes (TTHMs) and Haloacetic Acids (HAA5s), including instructions for completing this form. This form is also available in MS Excel format.
TTHM HAA5 OEL Calculator TTHM HAA5 OEL Calculator - This MS Excel spreadsheet can be used to calculate the Operational Evaluation Level (OEL) For Total Trihalomethanes (TTHMs) and Haloacetic Acids (HAA5s).
Stage 2 DBPR Operational Evaluation Report Stage 2 DBPR Operational Evaluation Report - The Stage 2 DBPR Operational Evaluation Report 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. This form is also available in MS Word format.

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Surface Water Treatment Rules (SWTR)

Form Description
Instructions for SWTR Monthly Operating Reports Instructions for SWTR Monthly Operating Reports - Includes: Instructions for All Types of Filtration; Instructions for Entry Point Residual Disinfectant; Instructions for Distribution System Disinfectant Residual; Instructions for Membrane Filtration; and Instructions for Ultraviolet Disinfection.
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. The form is also available in MS Word format and in MS Excel format for use in completing the report on your computer.
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. The form is also available in MS Word format and in MS Excel format for use in completing the report on your computer.
LT1SWTR Form for Alternative Technology Filtration (MF, UL, RO) LT1SWTR Form for Alternative Technology Filtration (MF, UL, RO) - Use this form if your system uses Membrane Filtration (Microfiltration, Ultrafiltration, or Reverse Osmosis). This form asks for disinfectant residual and turbidity data and for you to perform certain calculations. The form is also available in MS Word format and in MS Excel format for use in completing the report on your computer.
LT1SWTR Form for Alternative Technology Filtration (BF, DE, SS, CT) LT1SWTR Form for Alternative Technology Filtration (BF, DE, SS, CT) - Use this form if your system uses bag filtration, diatomaceous earth, slow sand, or cartridge filtration. This form asks for disinfectant residual and turbidity data and for you to perform certain calculations. The form is also available in MS Word format and in MS Excel format for use in completing the report on your computer.
SWTR Daily Reporting Sheet for UV Systems SWTR Daily Reporting Sheet for UV Systems - This form should be completed and submitted monthly to EPA Region 8 when a small (generally < 40 gpm) public water system utilizes ultraviolet disinfection. The form is also available in MS Word format and in MS Excel format for use in completing the report on your computer.
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).

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Training (TRN)

Form Description
Training Needs Survey Form Training Needs Survey Form - This form can be used to tell EPA about your drinking water training needs. This template is also available in MS Word format.

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