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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