2019 CCR Report 2019 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 email/fax/mail/file upload..*Yes, I am emailing my report copies to msrwa@msrwa.orgYes, I am Faxing my report copies to 601-857-2433Yes, I am mailing copies of my report to MsRWA, 5400 N Midway Rd, Raymond, MS 39154Yes, I am uploading my report now.Upload CCR Report Copies*MEMBER RATE $80/PWS ID*01-$802-$1603-$2404-$3205-$4006-$4807-$5608-$6409-$72010-$800MsRWA Membership FormUpload Your MsRWA Membership Form to get Member Rate. (Membership will be invoiced, unless paid online already.)NON-MEMBER RATE $160/ PWS ID*To become a MsRWA Member go to msrwa.org/membership/ 01-$1602-$3203-$4804-$6405-$8006-$9607-$1,1208-$1,2809-$1,44010-$1,600Please Email my CCR*$15.00 FeeNo, do not email.Yes, Email $15Email* Please mail me a CD*$15 Fee (CD will have CCR in PDF Format)No, I do not want a CDYes, Please mail a CD- $15CCR Hosting on MsRWA Website $165/3 Years*(2019 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 HostedYes, Please Host my CCR for the next 3 Years - $165Late 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, 2020Yes, I am submitting after June 17, 2020 - $100Total $0.00 Name of System*PWS ID# (s)*Full Mailing Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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 MeetingDate of MeetingTime of Meeting HH : MM 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 include a copy of the fluoride letter.Fluoride Letter Revised Total Coliform Rule (RTCR)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 LevelLevel 1Level 2Complete 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.If you were required to send a public notice to your customers, Please attach a copy. Did your system have ANY violations?NoYesWere you required to send a public notice to your customers, if so please attach a copy.If yes, what type of violation and when?MajorMinorMonitoringDate of Violation: Date Format: MM slash DD slash YYYY Please Explain Violations:Did your system have any significant deficiency (s) in 2019?NoYesIf yes include a copy of the Ground Water Rule Significant Dificiency Summary Report.Lead & CooperWhat is your system's sampling schedule for L&C?Every Three YearsAnnuallyEvery 6 MonthsPlease provide a copy of the latest Lead & Cooper 90th Percentile PageDid 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: HH : MM 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.Additional Information 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.CCR Report Forms will be sent Via:*File UploadEmail: msrwa@msrwa.orgFax: 601-857-2433Mailed: 5400 N Midway Rd, Raymond MS 39154Upload Any Report forms you might have missed here:Date* Date Format: MM slash DD slash YYYY System Name*Name* First Last Preferred payment method*Pay online w/ credit cardMail a checkOtherTotal $0.00 PhoneThis field is for validation purposes and should be left unchanged.
