Free 46977.pdf - Indiana

Please return form to: IDEM-Drinking Water Branch or 100 N. Senate Ave. Mail Code 66-34 NEW SYSTEM QUESTIONNAIRE Indianapolis, IN 46204-2251 State Form 46977 (R2 /6-07) FAX: (317) 308-3340 Indiana Department of Environmental Management (IDEM) or IDEM-SWRO in Petersburg or P.O. Box 128 Petersburg, IN 47567 FAX: (812) 380-2304
SYSTEM NAME: PHYSICAL FACILITY ADDRESS: CITY: STATE: INDIANA ZIP:

IDEM-NRO in South Bend 220 W. Colfax Ave., Ste. 200 South Bend, IN 46601 FAX: (574) 245-4877 IDEM-NWRO 8315 Virginia St., Ste. 1 Merrillville, IN 46410 FAX: (219) 757-0267

County:
PHONE:

Water Supplied by: Ground Water
Number of Wells:
Population (Residential):

Surface Water Water Company (Name____________________________)
Number of Service Connections: (buildings, trailers, units, etc.)
*Population (Non-Transient):

Depth of Well(s):
*Population (Transient):

*Number of Entry Points (to distribution system):

Is this Well Seasonal? YES
Service Areas: Hotel/Motel Recreational Area Course Golf

NO

N/A

If yes, give the dates: From
Mobile Home Park Municipality Residential Area Nursing Home

To
Restaurant School Institution Area Rest Store Airport Church

Care Center Day Office Building Service Station Summer Camp Industrial/Agricultural Medical Facility Subdivision Campground Other, Specify: _______________________________________________ Type of Ownership:

Federal Government Local Government Private Municipal Native American Other, Specify: _______________________________________________

State Government Non-Profit

MAILING INFORMATION
ADDRESS: CITY: MAILING NAME (First) MAILING TITLE:

(Individual responsible for communication with IDEM via mail.)

STATE:

ZIP:

EMAIL: MR./MS./MRS.

(Last) PHONE( ) EXT:

OPERATOR INFORMATION
ADDRESS:

(Individual responsible for operation, maintenance, and sampling.) EMAIL:

CITY: OPERATOR NAME (First)

STATE: (Last)
(Owner or ultimately responsible party.)

ZIP: PHONE (

ARE YOU A CERTIFIED OPERATOR? (Y or N): ) EXT:

OWNER INFORMATION
ADDRESS: CITY:

EMAIL: STATE: ZIP:

**FED/IRS ID or SSN: PHONE( ) EXT:

OWNER NAME (First)

(Last)

BILLING INFORMATION
ADDRESS BILLING NAME: (First) TITLE:

(Financial contact for Drinking Water fees. Please provide a year-round address.) CITY: (Last) PHONE( ) EXT: FAX ( ) STATE: ZIP:

*An Entry Point: The point where the water enters the distribution system; after all treatment (chlorination, softening, etc.), but before entry into the distribution system. *Transient Population: An average number of people served daily by a facility (at least 60 days per year) *Non-Transient Population: An average number of the same persons which are served regularly by a facility (at least 6 months or 180 days per year) **FED/IRS ID or SSN: The federal tax identification number issued by the IRS (ex. 00-1234567) or owner's social security number. This information will remain confidential and will not be disclosed for any reason.

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System Name: ________________________________________

Comments/Reason For Change:

Complexity of Treatment: Pressure tank
(Circle all that apply)

Softener Pressure filtration Chlorination: Gas Liquid Pellet

RO

Other___________

Was Building Construction Date AFTER 10/01/1999?

Circle one

System Type: Transient PWS

YES

NO

Non-Transient PWS Community PWS

(Needed For Capacity Development)

Field Signature: Changed By:

Date Signed (mm/dd/yy): Date Changed (mm/dd/yy):

Flow Diagram: Please sketch the water flow from source, through storage, treatment and how the distribution system is set up.