Pennsylvania Department of Environmental Protection
RTCR SEASONAL START-UP ANNUAL CERTIFICATION FORM
Seasonal Public Water System Name:
PWS ID #:
Note: Contact the appropriate DEP district office if you close later than the season end date specified in your Seasonal Start-Up Procedures.
|Certification: |
| |
|As a representative of the Public Water System (PWS) indicated above, I certify the following: |
| |
|For this calendar year, the PWS has a season begin date of . |
|Approved start-up procedures were completed. |
|Coliform sample(s) were collected at the location(s) specified in the system’s start-up procedure. |
|The most recent set of samples collected were absent of coliform bacteria. |
| |
|Signature: Date: |
| |
|Print Name and Title: |
| |
|Phone Number: |
Complete and submit this form to the appropriate DEP district office prior to serving water to the public each season.
The form should be mailed to DEP – Safe Drinking Water, at the appropriate district office address from the list on the back of this form. For counties marked with an asterisk (*), address to the appropriate County Health Department (CHD), which is an agent of DEP for the Safe Drinking Water Program.
DEP Office and County Health Department Contact Information by County
|County |Address |Telephone # |
|Adams |York District Office |717-771-4481 |
| |150 Roosevelt Ave., Suite 200, York, PA 17401 | |
|Allegheny |Allegheny County Health Department |412-578-8047 |
| |3901 Penn Ave., Building 5, Pittsburgh, PA 15224 | |
|Armstrong |New Stanton District Office |724-925-5500 |
| |131 Broadview Rd., New Stanton, PA 15672 | |
|Beaver |Beaver Falls District Office |724-847-5271 |
| |715 15th St., Beaver Falls, PA 15010 | |
|Bedford |Altoona District Office |814-946-7292 |
| |3001 Fairway Dr., Altoona, PA 16602 | |
|Berks |Reading District Office |610-916-0100 |
| |1005 Cross Roads Blvd., Reading, PA 19605 | |
|Blair |Altoona District Office |814-946-7292 |
| |3001 Fairway Dr., Altoona, PA 16602 | |
|Bradford |Mansfield District Office |570-662-0830 |
| |600 Gateway Dr., Mansfield, PA 16933 | |
|Bucks |Southeast Regional Office |484-250-5980 |
| |2 E. Main St., Norristown, PA 19401 | |
|Butler |New Castle District Office |724-656-3160 |
| |121 N. Mill St., New Castle, PA 16101 | |
|Cambria |Cambria District Office |814-472-1900 |
| |286 Industrial Park Rd., Ebensburg, PA 15931 | |
|Cameron |Moshannon District Office |814-342-8200 |
| |186 Enterprise Dr., Philipsburg, PA 16866 | |
|Carbon |Pottsville District Office |570-621-3118 |
| |5 W. Laurel Blvd., Pottsville, PA 17901 | |
|Centre |Moshannon District Office |814-342-8200 |
| |186 Enterprise Dr., Philipsburg, PA 16866 | |
|Chester |Southeast Regional Office |484-250-5980 |
| |2 E. Main St., Norristown, PA 19401 | |
|Clarion |Knox District Office |814-797-1191 |
| |PO Box 669, Knox, PA 16232 | |
|Clearfield |Moshannon District Office |814-342-8200 |
| |186 Enterprise Dr., Philipsburg, PA 16866 | |
|Clinton |Moshannon District Office |814-342-8200 |
| |186 Enterprise Dr., Philipsburg, PA 16866 | |
|Columbia |Sunbury District Office |570-988-5500 |
| |309 N. 5th St., Suite D, Sunbury, PA 17801 | |
|Crawford |Northwest Regional Office |814 -332-6899 |
| |230 Chestnut St., Meadville, PA 16335 | |
|Cumberland |York District Office |717-771-4481 |
| |150 Roosevelt Ave., Suite 200, York, PA 17401 | |
|Dauphin |Southcentral Regional Office |717-705-4708 |
| |909 Elmerton Ave., Harrisburg, PA 17110 | |
|Delaware |Southeast Regional Office |484-250-5980 |
| |2 E. Main St., Norristown, PA 19401 | |
|Elk |Warren District Office |814-723-3273 |
| |321 N. State St., North Warren, PA 16365 | |
|Erie |For Community & Nontransient PWS: |For Transient PWS: |Warren: |
| | | |814-723-3273 |
|Note: address differs |Warren District Office |Erie County Health Dept. | |
|depending on system type |321 N. State St. |Drinking Water Program |Erie CHD: |
| |North Warren, PA 16365 |606 W. Second St., Erie, PA 16507 |814-451-6700 |
|County |Address |Telephone # |
|Fayette |California District Office |724-769-1100 |
| |25 Technology Dr., Coal Center, PA 15423 | |
|Forest |Warren District Office |814-723-3273 |
| |321 N. State St., North Warren, PA 16365 | |
|Franklin |York District Office |717-771-4481 |
| |150 Roosevelt Ave., Suite 200, York, PA 17401 | |
|Fulton |York District Office |717-771-4481 |
| |150 Roosevelt Ave., Suite 200, York, PA 17401 | |
|Greene |California District Office |724-769-1100 |
| |25 Technology Dr., Coal Center, PA 15423 | |
|Huntingdon |Altoona District Office |814-946-7292 |
| |3001 Fairway Dr., Altoona, PA 16602 | |
|Indiana |Cambria District Office |814-472-1900 |
| |286 Industrial Park Rd., Ebensburg, PA 15931 | |
|Jefferson |Knox District Office |814-797-1191 |
| |PO Box 669, Knox, PA 16232 | |
|Juniata |Southcentral Regional Office |717-705-4708 |
| |909 Elmerton Ave., Harrisburg, PA 17110 | |
|Lackawanna |Scranton District Office |570-963-4521 |
| |321 Spruce St., Suite 300, Scranton, PA 18503 | |
|Lancaster |Lancaster District Office |717-299-7601 |
| |1661 Old Philadelphia Pike, Lancaster, PA 17602 | |
|Lawrence |New Castle District Office |724-656-3160 |
| |121 N. Mill St., New Castle, PA 16101 | |
|Lebanon |Lancaster District Office |717-299-7601 |
| |1661 Old Philadelphia Pike, Lancaster, PA 17602 | |
|Lehigh |Bethlehem District Office |610-861-2070 |
| |4530 Bath Pike, Bethlehem, PA 18017 | |
|Luzerne |Northeast Regional Office |570-826-2511 |
| |2 Public Square, Wilkes-Barre, PA 18701 | |
|Lycoming |Northcentral Regional Office |570-327-3490 |
| |208 W. Third St., Suite 101, Williamsport, PA 17701 | |
|McKean |Warren District Office |814-723-3273 |
| |321 N. State St., North Warren, PA 16365 | |
|Mercer |Southern Mercer County: |Northern Mercer County: |New Castle: |
| | | |724-656-3160 |
| |New Castle District Office |Northwest Regional Office | |
| |121 N. Mill St. |230 Chestnut St. |Meadville: |
| |New Castle, PA 16101 |Meadville, PA 16335 |814-332-6899 |
|Mifflin |Altoona District Office |814-946-7292 |
| |3001 Fairway Dr., Altoona, PA 16602 | |
|Monroe |Pocono District Office |570-895-4040 |
| |2174B Route 611, Swiftwater, PA 18370 | |
|Montgomery |Southeast Regional Office |484-250-5980 |
| |2 E. Main St., Norristown, PA 19401 | |
|Montour |Sunbury District Office |570-988-5500 |
| |309 N. 5th St., Suite D, Sunbury, PA 17801 | |
|Northampton |Bethlehem District Office |610-861-2070 |
| |4530 Bath Pike, Bethlehem, PA 18017 | |
|Northumberland |Sunbury District Office |570-988-5500 |
| |309 N. 5th St., Suite D, Sunbury, PA 17801 | |
|Perry |Southcentral Regional Office |717-705-4708 |
| |909 Elmerton Ave., Harrisburg, PA 17110 | |
|County |Address |Telephone # |
|Philadelphia |Southeast Regional Office |484-250-5980 |
| |2 E. Main St., Norristown, PA 19401 | |
|Pike |Pocono District Office |570-895-4040 |
| |2174B Route 611, Swiftwater, PA 18370 | |
|Potter |Mansfield District Office |570-662-0830 |
| |600 Gateway Dr., Mansfield, PA 16933 | |
|Schuylkill |Pottsville District Office |570-621-3118 |
| |5 W. Laurel Blvd., Pottsville, PA 17901 | |
|Snyder |Sunbury District Office |570-988-5500 |
| |309 N. 5th St., Suite D, Sunbury, PA 17801 | |
|Somerset |Cambria District Office |814-472-1900 |
| |286 Industrial Park Rd., Ebensburg, PA 15931 | |
|Sullivan |Northcentral Regional Office |570-327-0540 |
| |208 W. Third St., Suite 101, Williamsport, PA 17701 | |
|Susquehanna |Scranton District Office |570-963-4521 |
| |321 Spruce St., Suite 300, Scranton, PA 18503 | |
|Tioga |Mansfield District Office |570-662-0830 |
| |600 Gateway Dr., Mansfield, PA 16933 | |
|Union |Sunbury District Office |570-988-5500 |
| |309 N. 5th St., Suite D, Sunbury, PA 17801 | |
|Venango |Northwest Regional Office |814-332-6899 |
| |230 Chestnut St., Meadville, PA 16335 | |
|Warren |Warren District Office |814-723-3273 |
| |321 N. State St., North Warren, PA 16365 | |
|Washington |Beaver Falls District Office |724-847-5271 |
| |715 15th St., Beaver Falls, PA 15010 | |
|Wayne |Scranton District Office |570-963-4521 |
| |321 Spruce St., Suite 300, Scranton, PA 18503 | |
|Westmoreland |New Stanton District Office |724-925-5500 |
| |131 Broadview Rd., New Stanton, PA 15672 | |
|Wyoming |Northeast Regional Office |570-826-2511 |
| |2 Public Square, Wilkes-Barre, PA 18701 | |
|York |York District Office |717-771-4481 |
| |150 Roosevelt Ave., Suite 200, York, PA 17401 | |
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