Annual Report on Violations of Watershed Rules
and Regulations for the Calendar Year 20____
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Water Supply Protection
Section A. Identify Information
Year action taken 20
Enforcement of Rules and Regulations Part
Public Water Supply
Water Board or Company
Municipality
County
Section B. Inspections/Violations
Specify details of violations on reverse side.
1. Number of Inspections during the year 20
was
2. Total number of:
Violations found
Specify section of the Rules violated
Notices served
Specify section of the Rules violated
Violations corrected
Specify section of the Rules violated
3 Total number of violations remaining uncorrected as of January 1, 20
4. Do you wish to update or revise your rules?
Yes
is
No
Section C. Sanitary Conditions
Provide all pertinent information bearing upon the general conditions on the watershed
of the supply or in the vicinity of wells or springs used as the sources of water supply:
Signature
(Water Supply Official)
Print Name
Title
DOH-359 (8/10) Page 1 of 2
Date
MM
DD
YY
Section D. Details of Violations
VIOLATION 1
Name of Violator
Post Office Address of Violator
Township/Village of Violation
Detailed Description of
Violation and Rule(s) Violated
VIOLATION 2
Name of Violator
Post Office Address of Violator
Township/Village of Violation
Detailed Description of
Violation and Rule(s) Violated
VIOLATION 3
Name of Violator
Post Office Address of Violator
Township/Village of Violation
Detailed Description of
Violation and Rule(s) Violated
DOH-359 (8/10) Page 2 of 2