3930-FM-BSDW0076
Rev. 4/2015
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF SAFE DRINKING WATER
PUBLIC NOTIFICATION (PN) CERTIFICATION FORM
Public Water System Name:
PWSID Number:
Date of Violation:
Description of Violation:
Notified DEP (or CHD) within 1 hour
Date or NA:
Consulted with DEP within 24 hours
Date or NA:
PN Level:
Tier 1
Tier 2
Type of notice addressed by this certification:
Tier 3
Initial
Repeat
Methods and date of public notice deliveries to customers:
Method:
Date:
Method:
Date:
Method:
Date:
Method:
Date:
The public notice included the required elements: a description of the violation; potential health effects; the
population at risk; if alternate water supplies need to be used; when the violation occurred; when the system will
resolve the situation; what is being done to correct the problem; actions consumers can take; water system
contact information; and language encouraging broader distribution of the notice.
A copy of each type of notice that was distributed is attached to this certification form
Certified by:
As a representative of the Public Water System (PWS) indicated above, I certify that public notification addressing
the above violation was distributed to all customers in accordance with the prescribed content, format, deadlines and
delivery requirements outlined in Chapter 25 Pa. Code Chapter 109 Subchapter D of the Department of
Environmental Protection (DEP)'s regulations.
Signature:
Date:
Print Name and Title:
Phone Number:
Complete and submit this form to your local DEP office within 10 days of issuing the public notification described
above. A list of DEP district offices and CHD offices is on the back of this form.
For DEP use only. Checked by:
Date:
-1-
3930-FM-BSDW0076
Rev. 4/2015
Safe Drinking Water Program Regional Office and County Health Department Contact Information
for Public Notification (PN) Certification Form Submissions
Bucks, Chester, Delaware,
Montgomery, Philadelphia
Luzerne, Wyoming
Lackawanna, Susquehanna,
Wayne
Carbon, Schuylkill
Monroe, Pike
Lehigh, Northampton
Dauphin, Juniata, Perry
Bedford, Blair, Huntingdon, Mifflin
Adams, Cumberland, Franklin,
Fulton, York
Lancaster, Lebanon
Berks
Lycoming
Bradford, Potter, Sullivan, Tioga
Cameron, Centre, Clearfield,
Clinton
Columbia, Montour,
Northumberland, Snyder, Union
Allegheny
Armstrong, Westmoreland
Beaver, Washington
Fayette, Greene
Cambria, Indiana, Somerset
Clarion, Jefferson
Elk, Erie Forest, McKean, Warren
Butler, Lawrence, Southern
Mercer
Crawford, Northern Mercer,
Venango
Southeast Region
Norristown Regional Office
2 E. Main St., Norristown, PA 19401
Northeast Region
Wilkes-Barre Regional Office
2 Public Square, Wilkes-Barre, PA 18701-1915
Scranton District Office
321 Spruce St., Ste 300, Scranton, PA 18503
Pottsville District Office
5 W. Laurel Blvd., Pottsville, PA 17901-2454
Pocono District Office
2174B Route 611, Swiftwater, PA 18370
Bethlehem District Office
4530 Bath Pike, Bethlehem, PA 18017
Southcentral Region
Harrisburg Regional Office
909 Elmerton Ave., Harrisburg, PA 17110
Altoona District Office
3001 Fairway Dr., Altoona, PA 16602-4473
York District Office
150 Roosevelt Ave., Ste 200, York, PA 17401
Lancaster District Office
1661 Old Philadelphia Pike, Lancaster, PA 17602
Reading District Office
1005 Cross Roads Blvd., Reading, PA 19605
Northcentral Region
Williamsport Regional Office
208 W. Third St., Ste 101, Williamsport, PA 17701
Mansfield District Office
600 Gateway Dr., Mansfield, PA 16933
Moshannon District Office
186 Enterprise Dr., Philipsburg, PA 16866
Sunbury District Office
309 N. 5th St., Ste D, Sunbury, PA 17801-5500
Southwest Region
Allegheny County Health Department
3901 Penn Ave., Bldg. 5, Pittsburgh, PA 15224-1318
New Stanton District Office
131 Broadview Rd., New Stanton, PA 15672
Beaver Falls District Office
715 15th St., Beaver Falls, PA 15010
California District Office
25 Technology Dr., Coal Center, PA 15423
Cambria District Office
286 Industrial Park Rd., Ebensburg, PA 15931-4119
Northwest Region
Knox District Office
PO Box 669, Knox, PA 16232
Warren District Office
321 N. State St., Warren, PA 16365
New Castle District Office
121 N. Mill St., New Castle, PA 16101
Meadville Regional Office
230 Chestnut St., Meadville, PA 16335
-2-
Telephone
484-250-5980
570-826-2511
570-963-4521
570-621-3118
570-895-4040
610-861-2070
717-705-4708
814-946-7292
717-771-4481
717-299-7601
610-916-0100
570-327-3490
570-662-0830
814-342-8200
570-988-5500
412-578-8047
724-925-5500
724-847-5270
724-769-1100
814-472-1900
814-797-1191
814-723-3273
724-656-3160
814-332-6899