2022 CCR Report 2023 CCR Report Step 1 of 8 12% *No Report will be returned without payment. Please do not send your results on a CD. You may send a copy via mail/fax*Yes, I am Faxing my report copies to 601-857-2434Yes, I am mailing copies of my report to MsRWA, 172 Country Place Parkway, Pearl, MS 39208MEMBER RATE $150/PWS ID*01-$1502-$3003-$4504-$6005-$7506-$9007-$10508-$12009-$135010-$1500NON-MEMBER RATE $300/ PWS ID*To become a MsRWA Member go to msrwa.org/membership/ 01-$3002-$6003-$9004-$12005-$15006-$15007-$21008-$24009-$2,70010-$3,000Please Email my CCR Report* Yes, Email PDF Report to me No, Please mail a Paper copy. Email* CCR Hosting on MsRWA Website $175/3 Years*(CCR will be hosted on MsRWA Website and remain on the website as required for the next three years) No, I do not want my CCR Hosted. Yes, Please Host my CCR for the next 3 Years - $175 Late Fee accessed after June 17th - $100 Fee*All CCR's received after June 17th will be accessed a Late Fee! No, I am submitting before June 17 Yes, I am submitting after June 17 - $100 Total $0.00 Name of System* PWS ID# (s)* Full Mailing Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Contact Person Name (To be printed in report)* First Last Contact Phone (To be printed in report)*System Meetings are Held When* Monthly Annually Day of Meeting Date of Meeting Time of Meeting Hours : Minutes AM PM AM/PM Location of Meeting Street Address City State / Province / Region ZIP / Postal Code Name of Aquifer(s) Number of WellsPlease provide the following information from your system's Source Water Assessment Program(SWAP)Our wells received the following ranking of susceptibility to contamination. Please choose ONE!LowerLower to ModerateModerateLower to HigherModerate to HigherHigherDo you purchase water?NoYesIf Yes, System ID & System Name Purchased from: Does you system add fluorideNoYes, Please fax a copy of the fluoride letter. Revised Total Coliform Rule (RTCR)Did your system(s) have any bacteria present in 20201?NoYesWhat is the System ID# What Type?ColiformE-ColiWhat Month? How many routine samples were taken?How many samples tested positive for bacteria?Did your re-samples test positive for bacteria?YesNo Assessment Level*Level 1Level 2NoneComplete this statement for Level 1:"During the past year we were required to conduct _____ Level 1 assessment (s)__________ Level 1 assessment (s) were completed.In addition were were required to take __________ Corrective actionsWe completed __________ of these corrective actionsComplete this statement for Level 2:"During the past year we were required to conduct _____ Level 2 assessment (s) were required to be completed for our water system.We completed __________ of these corrective actionsIn addition we were required to take __________ Corrective actions__________ Level 2 assessment (s) were completed. Did your system have ANY violations?NoYes, Were you required to send a public notice to your customers, if so please fax a copy.If yes, what type of violation and when?MajorMinorMonitoringDate of Violation: MM slash DD slash YYYY Please Explain Violations:Did your system have any significant deficiency (s) in 2022?NoYes, If yes include a copy of the Ground Water Rule Significant Dificiency Summary Report.Lead & CooperWhat is your system's sampling schedule for L&C? Please fax a copy of the latest Lead & Cooper 90th Percentile PageEvery Three YearsAnnuallyEvery 6 MonthsDid the results exceed the action level for Lead & Cooper?NoYesIf yes, how many samplesWhich Containment Person to contact at your system if we need additional information:* First Last Position: Daytime Phone (8am - 5pm)*Cell PhoneBest time to contact: Hours : Minutes AM PM AM/PM Fax #Email address: You may add information to your report about your system, as a public relations tool. If you would like us to insert any additional information, please provide here or send on separate page. The MsRWa will not be responsible if the report is missing information that you did not provide to us.*Yes, I understand that the MsRWA can complete a true Consumer Confidence Report only if I provide them with the necessary information. If the MsRWA has to re-develop the report, extra charges will be incurred. I agree to the this statement.System MSDH Test Results will be sent Via:*Fax: 601-857-2434Mailed: 172 Country Place Parkway, Pearl, MS 39208Date* MM slash DD slash YYYY System Name* Name* First Last Preferred payment method* Pay online w/ credit card Mail a check Other Total $0.00 CommentsThis field is for validation purposes and should be left unchanged. Δ
