Drinking Water Forms

Forms are available in electronic format only (Word or PDF). You cannot order hard-copies through our offices or through our online publication ordering system. If you have questions concerning a form, contact your regional office.

Eastern Regional Office—Spokane Valley: 509-329-2100

Northwest Regional Office—253-395-6750

Southwest Regional Office—Tumwater: 360-236-3030

Form Categories

Consumer Confidence Report

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

Cross-Connection

331-154 (cream)—Cross-Connection Control Program Summary Report for 2015 (Word) | (PDF)

331-155 (blue)—Public Water System Cross-Connection Control Activities Annual Summary Report for 2015 (Word) | (PDF)

331-156 (green)—Exceptions to High-Health Hazard Premises Isolation Requirements for 2015 Annual Summary Report (Word) | (PDF)

331-434 (gray)—Cross-Connection Control Severe Health Hazard Facility Report for 2015 (Word) | (PDF)

331-457—Backflow Incident Report (Word) | (PDF)

331-476—Cross-Connection Control Specialist Public List Application Form (Word)

Disinfection

Chlorination

331-430—Source Disinfection Treatment Plant Report Form for CT6 and 4 log virus inactivation systems (Excel) | (Word)

331-593—Distribution Chlorine Residual Report Form for systems disinfecting their distribution system (Excel) | (Word)

Drinking Water State Revolving Fund

For information about Drinking Water State Revolving Fund forms, please visit the DWSRF page.

Engineering and Planning Submittals

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

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

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

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

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

331-568—Local Government Consistency Determination Form (Word)

Water Rights Self Assessment

331-370—Small Water System Management Program-- Water Rights Self Assessment (Word)

331-372—Water System Plan - Water Rights Self Assessment--10 and 20 Year Forecast (Word)

Groundwater Under the Direct Influence of Surface Water

331-189—Potential GWI Source Identification and Designation (Word) (PDF)

331-190—GWI Determination Process Purveyor's Choice (Word) | (PDF)

331-191—GWI Quality Monitoring Interview Documentation (Word) | (PDF)

331-192—GWI Water Quality Monitoring Confirmation (Word) | (PDF)

331-193—GWI Water Quality Monitoring Report Form (Word) | (PDF)

331-194—GWI Hydraulic Connectivity Determination, Analysis of Water Quality Monitoring Data (Word) | (PDF)

331-195—GWI Hydraulic Connectivity Determination, Descriptive Statistics (Word) | (PDF)

Operator Certification

331-418—Operator Complaint Form (Word) | (PDF)

331-439—Contract Operator Public Listing Form (Word)

331-476—Cross-Connection Control Specialist Public List Information Form (Word) | (PDF)

Public Notification

331-163—Coliform Monitoring Violation Public Notice (Word) | (PDF)

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

331-264—Public Notice Certification Coliform MCL (Word) | (PDF)

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

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

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

331-360—Spanish - Disinfection Byproducts Monitoring Violation (Word) | (PDF)

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

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

331-412—Quarterly Nitrate Monitoring Violation Form (Word) | (PDF)

331-416—Notice to Water System Users: Reliably and Consistently Under the Maximum Contaminant Level - Annual Nitrate Monitoring Violation Form (Word) | (PDF)

331-461—Lead and Copper Monitoring Violation - English and Spanish (Word) | (PDF)

331-462—Lead and Copper Consumer Notice Requirements and Certification (Word) | (PDF)

331-465—Notice to Water System Users, Chemical Monitoring Violation (Word) | (PDF)

331-493—Drinking Water Warning: Loss of Pressure (Word)

331-495—Drinking Water Warning: Backflow Incident (Word)

331-691—Universal Chemical Monitoring Violation Form (PDF) | (Word)

Sanitary Survey Forms

331-487—Third-Party Sanitary Survey Checklist (Word)

331-638—Public Water System Well Site Inspection Form (Word)

Surface Water Treatment Forms

Monthly Report Workbooks

You will need Microsoft Excel 97 or a later version on your computer to use these forms. They include:

  • Water Treatment Plant Monthly Report.
  • SWTR Disinfection Monthly Report.
  • Surface Water Treatment Plant Monthly Report Summary.

Each Excel file includes a Contact Time (CT) look up table. For each technology listed in the Monthly Report Workbooks below, three forms 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.

    Other Surface Water Treatment Forms

    Water Quality

    Coliform

    331-319-F—Coliform Bacteria Analysis Form (Word) (Note: Regular size form 11 in x 4 in.)

    331-320-F—Coliform Bacteria Analysis Form (Word) (Note: Same form as 331-319-F but 5 in. x 8 in. and designed to fit into a window envelope.)

    Completing the above forms

    1. Save the templates to your computer.
    2. Text in "Red" can be deleted so you can add your name, address, and your Ecology-accredited Method Code.

    Printing the form: The forms are designed to print 100%. Page scaling options are available by selecting "file" and then "print."

    Public notification templates

    • Boil Water Door Hanger—English and Spanish (Word) | (PDF)
    • Drinking Water Warning—Community (Word) | (PDF)
    • Drinking Water Warning—Noncommunity (Word) | (PDF)

    Disinfection Byproducts

    331-464—Stage 2 Disinfection Byproducts Monitoring Plan (Excel)

    The two organizations below can help you complete these forms.

    Epichlorohydrin and Acrylamide

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

    Fluoridation

    • 331-496—Fluoridation Monthly Operations Report Form for Sodium Fluoride Saturators (Excel) | (PDF)
    • 331-497—Fluorosilicic Acid Sodium Fluorosilicate (Excel) | (PDF)

    Water Use Efficiency

    Annual Water Use Efficiency Performance Report—new online reporting form.