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—509-329-2100

Northwest Regional Office—253-395-6750

Southwest Regional Office—360-236-3030

Form Categories

Consumer Confidence Report

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

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 )

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)

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 Word | PDF

331-735—Manganese Health Advisory Above 1.0 mg/L (Word)

331-736—Manganese Health Advisory Above 0.3 mg/L (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.