Pennsylvania Department of Environmental Protection

3900-FM-BSDW0521 8/2013 COMMONWEALTH OF PENNSYLVANIA Instructions DEPARTMENT OF ENVIRONMENTAL PROTECTION BUREAU OF SAFE DRINKING WATER

Please remove and recycle these instructions prior to sending the competed form to DEP

Instructions for Operational Evaluation Level (OEL) Exceedance Notification Form

GENERAL INFORMATION

Pennsylvania’s Stage 2 Disinfection Byproducts Rule (DBPR) requires all public water supply systems that are collecting Stage 2 compliance samples on a quarterly frequency to calculate an Operational Evaluation Level (OEL) at each sampling location in accordance with the PA Safe Drinking Water Regulations,§109.701(g)(2)(iii).

The purpose of the OEL is to assist systems that have increasing levels of disinfection byproducts (DBPs) to determine the cause and reverse the trend before a violation occurs. The OEL must be calculated by the water system at the end of the 3rd quarter (after the Stage 2 DBPR compliance monitoring begin date), and then every quarter thereafter as long as the system is on a quarterly monitoring frequency. The OEL calculation is the sum of the two previous quarterly (qrtr) results plus twice the current quarter’s result, divided by four. The formula is as follows: OEL = [(result from 2 qrtrs prior to current qrtr) + (result from previous qrtr) + 2(current qrtr result)] 4 The OEL must be calculated for both Total Trihalomethanes (TTHMs) and Haloacetic Acids (HAA5s) at each monitoring location. If the calculated OEL for any location exceeds the Maximum Contaminant Level (MCL) for either TTHMs (0.080 mg/L) or HAA5s (0.060 mg/L), the water system is required to notify the Department (DEP) within 10 days of the end of the quarter in which the OEL exceedance occurs. This form should be completed by a water system with an OEL exceedance and used to fulfill the notification requirement within the 10-day deadline.

Additionally, if an OEL exceedance occurs, the water system is required to conduct an Operational Evaluation to identify the cause of the exceedance and submit a report to DEP within 90 days of the date the sample result that triggered the exceedance is received by the water system. If the water system can immediately identify the cause of the OEL exceedance, a limited scope evaluation may be requested in lieu of the full evaluation and report. To be eligible for a limited scope evaluation, the water system must be able to determine the cause of the OEL exceedance to the satisfaction of the DEP.

EPA has created the Operational Evaluation Guidance Manual to assist water systems in determining the cause of exceedances. DEP’s Drinking Water website provides links to this manual at: http://www.portal.state.pa.us/portal/server.pt?open=514&objID=553892&mode=2

ITEM-BY-ITEM INSTRUCTIONS

Section I: System Information

Section I is to identify the public water system that is submitting the OEL exceedance notification form. PWS Name: Name of the public water system (PWS). PWS ID: The seven-digit public water system identification number assigned by DEP. Contact Name: Name of the person who is the point of contact for OEL determination within the PWS. Phone #: Phone number of the contact person.

Section II: OEL Exceedance Information

Section II is to identify the sampling location(s) that exceeded, when the exceedance occurred, and the OEL calculation that was completed by the water system.

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There are two OEL exceedance tables under this section requiring the same information; a separate table should be used for each location that has an exceedance. If the system incurred one exceedance, then only one table should be completed. If there were OEL exceedances at multiple locations within the distribution system, then additional tables should be completed for each location. If more than two locations have an exceedance, there are additional tables listed on page 2 of this form.

OEL Exceedance Table:  DEP Sample Location ID#: The 3-digit number (7xx) you use to identify your Stage 2 sampling locations (specified on your IDSE Report or Monitoring Plan)  Sample Location Name: The name that you use when referring to the sampling location (ex. High St. Storage Tank)  Sample Date: The date that the most recent quarterly sample was collected  Sample Received Date: The date that the most recent quarterly sample result was received from the lab  Monitoring Period: The quarter in which the sample was collected (ex. 3rd quarter 2014)  TTHM: Calculated OEL Value: The value received from the OEL calculation for TTHM  OEL Calculation (for TTHM): The TTHM results from the previous two monitoring quarters and the current quarter should be entered into the parenthesis to demonstrate how the OEL was calculated.  HAA5: Calculated OEL Value: The value received from the OEL calculation for HAA5  OEL Calculation (for HAA5): The HAA5 results from the previous two monitoring quarters and the current quarter should be entered into the parenthesis to demonstrate how the OEL was calculated.

Section III: OEL Report Information

Section III identifies whether the water system is requesting a limited scope evaluation and if so, the reason for the OEL exceedance must be included. If the limited scope evaluation is not requested, the due date for the OEL report must be included. The OEL report must be submitted to DEP within 90 days from the sample received date of the sample that triggered the OEL exceedance. Question 1: Are you requesting a limited scope evaluation?: Check YES or NO. You may only answer YES if your water system can determine the reason for the OEL exceedance. Question 2: If yes, please provide reason of OEL exceedance: This answer should be a brief description of the reason; for example “Predisinfection chlorine feed rates were unusually high.” This is a form field that will allow you to type as much information as is needed to explain the exceedance (i.e. you are not limited to only a few words). Question 3: Due date for OEL Report: The due date for the report is 90 days from the sample received date identified in the OEL exceedance table in Section II.

Section IV: Verification

The responsible official for the water system must verify the information provided in form is accurate and correct. The name of the responsible official should be printed and that individual must sign and date the form.

MAILING

The completed form must be submitted to DEP by the 10th of the month following the quarter in which the OEL exceedance occurs. For example, if an OEL exceedance occurs in the October 1 to December 31 quarter, this completed form must be received by DEP no later than January 10th.

The completed form should be addressed to: PA DEP – Safe Drinking Water, at the address of the appropriate district office having jurisdiction over the water company (from the list on pages 3-4). 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 AND CHD OFFICES CONTACT LIST

PWS ID# Telephone County Address 1st 3 Digits Number Adams 701 150 Roosevelt Ave., Ste 200, York, PA 17401-3381 (717) 771-4481 Allegheny Co. Health Dept., PDWWM, Bldg #5, *Allegheny 502 (412) 578-8047 3901 Penn Ave., Pittsburgh, PA 15224-1347 Armbrust Prof. Ctr., 8205 Route 819, Armstrong 503 (724) 925-5400 Greensburg, PA 15601 Beaver 504 715 15th St., Beaver Falls, PA 15010 (724) 847-5270 Bedford 405 3001 Fairway Dr., Altoona, PA 16602-4473 (814) 946-7292 Berks 306 1005 Cross Roads Blvd., Reading, PA 19605 (610) 916-0100 Blair 407 3001 Fairway Dr., Altoona, PA 16602-4473 (814) 946-7292 Bradford 208 600 Gateway Dr., Mansfield, PA 16933 (570) 662-0830 Bucks 109 2 E. Main St., Norristown, PA 19401 (484) 250-5900 Butler 510 121 N. Mill St., New Castle, PA 16101 (724) 656-3160 Cambria 411 286 Industrial Park Rd., Ebensburg, PA 15931-4119 (814) 472-1900 Cameron 612 600 Gateway Dr., Mansfield, PA 16933 (570) 662-0830 Carbon 313 5 West Laurel Blvd., Pottsville, PA 17901-2454 (570) 621-3118 Centre 414 186 Enterprise Dr., Phillipsburg, PA 16866 (814) 342-8200 Chester 115 2 E. Main St., Norristown, PA 19401 (484) 250-5900 Clarion 616 1st Floor, White Memorial Bldg., Knox, PA 16232 (814) 797-1191 Clearfield 617 186 Enterprise Dr., Phillipsburg, PA 16866 (814) 342-8200 Clinton 418 208 W. Third St., Suite 101, Williamsport, PA 17701 (570) 327-3490 309 N. 5th St., Suite D, Columbia 419 (570) 988-5500 Sunbury, PA 17801-2003 Crawford 620 230 Chestnut St., Meadville, PA 16335-3481 (814) 332-6899 Cumberland 721 150 Roosevelt Ave., Ste 200, York, PA 17401-3381 (717) 771-4481 Dauphin 722 909 Elmerton Avenue, Harrisburg, PA 17110 (717) 705-4708 Delaware 123 2 E. Main St., Norristown, PA 19401 (484) 250-5900 Elk 624 321 N. State St., North Warren, PA 16365 (814) 723-3273 *Erie 625 230 Chestnut St., Meadville, PA 16335-3481 (814) 332-6899 Fayette Co. Health Center, Fayette 526 (724) 439-7332 100 New Salem Rd., Uniontown, PA 15401 Forest 627 321 N. State St., North Warren, PA 16365 (814) 723-3273 Franklin 728 150 Roosevelt Ave., Ste 200, York, PA 17401-3381 (717) 771-4481 Fulton 429 150 Roosevelt Ave., Ste 200, York, PA 17401-3381 (717) 771-4481 Fayette Co. Health Center, Greene 530 (724) 439-7332 100 New Salem Rd., Uniontown, PA 15401 Huntingdon 431 3001 Fairway Dr., Altoona, PA 16602-4473 (814) 946-7292 Indiana 532 286 Industrial Park Rd., Ebensburg, PA 15931-4119 (814) 472-1900 Jefferson 633 1st Floor, White Memorial Bldg., Knox, PA 16232 (814) 797-1191 Juniata 434 909 Elmerton Avenue, Harrisburg, PA 17110 (717) 705-4708

DEP AND CHD OFFICES CONTACT LIST (cont.)

PWS ID# Telephone County Address 1st 3 Digits Number Room 400, Samters Bldg., 101 Penn Ave., Lackawanna 235 (570) 963-4521 Scranton, PA 18503-2025 Lancaster 736 1661 Old Philadelphia Pike, Lancaster, PA 17602 (717) 299-7601 Lawrence 637 121 N. Mill St., New Castle, PA 16101 (724) 656-3160 Lebanon 738 1661 Old Philadelphia Pike, Lancaster, PA 17602 (717) 299-7601 Lehigh 339 4530 Bath Pike, Bethlehem, PA 18017 (610) 861-2070 Luzerne 240 2 Public Square, Wilkes-Barre, PA 18701-1915 (570) 826-2511 Lycoming 441 208 W. Third St., Suite 101, Williamsport, PA 17701 (570) 327-3490 McKean 642 321 N. State St., North Warren, PA 16365 (814) 723-3273 Mercer 643 121 N. Mill St., New Castle, PA 16101 (724) 656-3160 Mifflin 444 3001 Fairway Dr., Altoona, PA 16602-4473 (814) 946-7292 Monroe 245 2174 Route 611 #B, Swiftwater, PA 18370 (570) 895-4040 Montgomery 146 2 E. Main St., Norristown, PA 19401 (484) 250-5900 309 N. 5th St., Suite D, Montour 447 (570) 988-5500 Sunbury, PA 17801-2003 Northampton 348 4530 Bath Pike, Bethlehem, PA 18017 (610) 861-2070 309 N. 5th St., Suite D, Northumberland 449 (570) 988-5500 Sunbury, PA 17801-2003 Perry 750 909 Elmerton Avenue, Harrisburg, PA 17110 (717) 705-4708 Philadelphia 151 2 E. Main St., Norristown, PA 19401 (484) 250-5900 Pike 252 2174 Route 611 #B, Swiftwater, PA 18370 (570) 895-4040 Potter 653 600 Gateway Dr., Mansfield, PA 16933 (570) 662-0830 Schuylkill 354 5 West Laurel Blvd., Pottsville, PA 17901-2454 (570) 621-3118 309 N. 5th St., Suite D, Snyder 455 (570) 988-5500 Sunbury, PA 17801-2003 Somerset 456 286 Industrial Park Rd., Ebensburg, PA 15931-4119 (814) 472-1900 Sullivan 257 600 Gateway Dr., Mansfield, PA 16933 (570) 662-0830 Room 400, Samters Bldg., 101 Penn Ave, Susquehanna 258 (570) 963-4521 Scranton, PA 18503-2025 Tioga 259 600 Gateway Dr., Mansfield, PA 16933 (570) 662-0830 309 N. 5th St., Suite D, Union 460 (570) 988-5500 Sunbury, PA 17801-2003 Venango 661 121 N. Mill St., New Castle, PA 16101 (724) 656-3160 Warren 662 321 N. State St., North Warren, PA 16365 (814) 723-3273 Washington 563 715 15th St., Beaver Falls, PA 15010 (724) 847-5270 Room 400, Samters Bldg., 101 Penn Ave., Wayne 264 (570) 963-4521 Scranton, PA 18503-2025 Armbrust Prof. Ctr., 8205 Route 819, Westmoreland 565 (724) 925-5400 Greensburg, PA 15601 Wyoming 266 2 Public Square, Wilkes-Barre, PA 18701-1915 (570) 826-2511 York 767 150 Roosevelt Ave., Ste 200, York, PA 17401-3381 (717) 771-4481

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OPERATIONAL EVALUATION LEVEL (OEL) EXCEEDANCE NOTIFICATION FORM

Section I: System Information

PWS Name: PWSID #:

Contact Name: Phone #:

Section II: OEL Exceedance Information*

Water Systems on quarterly monitoring must calculate the OEL for each location each quarter (qrtr) as follows: OEL = [( result from 2 qrtrs prior to current qrtr) + (result from previous qrtr) + 2(current qrtr result) ] 4 An OEL exceedance occurs if either the TTHM OEL value is > 0.080 mg/L or the HAA5 OEL value is > 0.060 mg/L.

DEP Sample Location ID# DEP Sample Location ID# (3-digit # starting with “7”) (3-digit # starting with “7”) Sample Location Name Sample Location Name Sample Date Sample Date

(most recent quarterly sample) (most recent quarterly sample)

Sample Received Date Sample Received Date (date result received from lab) (date result received from lab) Monitoring Period (Qtr) Monitoring Period (Qtr) TTHM: Calculated TTHM: Calculated

OEL Value OEL Value OEL Calculation: [( ) + ( ) + 2( )] / 4 OEL Calculation: [( ) + ( ) + 2( )] / 4 HAA5: Calculated HAA5: Calculated

OEL Value OEL Value OEL Calculation: [( ) + ( ) + 2( )] / 4 OEL Calculation: [( ) + ( ) + 2( )] / 4

*Please use page 2 of this form to report additional OEL exceedances, if more than 2 locations exceeded the OEL during the quarter.

Section III: OEL Report Information

Are you requesting a limited scope evaluation? YES NO. If yes, please provide reason for OEL exceedance:

Due Date for OEL Report: (i.e. 90 days from the sample received date)

Section IV: Verification

Responsible Official’s Name (printed):

Responsible Official’s Signature: Date:

NOTE: The completed form must be submitted to DEP by the 10th of the month following the quarter in which the OEL exceedance occurs. For example, if an OEL exceedance occurs in the October 1 to December 31 quarter, this completed form must be

- 1 - 3900-FM-BSDW0521 8/2013 received by DEP no later than January 10th. Mail all OEL Exceedance Notification Forms to your local DEP Office. A list of all DEP and County Health Department (CHD) Offices is included in the instructions. Reporting for Additional OEL Exceedances (at 3 - 8 sampling locations)*

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*If you have more than 8 locations with an OEL exceedance in a quarter, make additional copies of this page as needed.