Document Text
--- Document: Annual Certification - Public Community Water Systems Document ---
DEP_10 S_00001.1
Revised 10/2022
Due
December 31
Do Not Mail. Form MUST be submitted via Portal.
Department of Environmental Protection – Division of Water Supply & Geoscience
Annual Certification Form for Public Community Water Systems
Name of Public Community Water System: ______________________________________________________
PWSID#: __________________ Licensed Operator(s) of Record: W# ____________________________
T# _____________________________
In accordance with the Water Quality Accountability Act (P.L. 2021, c.262 (C.58:31-6)), annual certification of
compliance with certain State and federal requirements is required by the following individual* from public community
water systems with >500 service connections:
•
The Responsible Corporate Officer (for investor-owned systems),
•
The Executive Director (for MUA’s), or
•
The Mayor or Chief Executive Officer (for municipally owned systems).
*Signing authority MAY NOT be delegated. For systems which do not have an organizational structure which provides
the referenced title, the Department must first be contacted to confirm that the individual with the equivalent role may
certify this form.
For each “Requirement” listed below, check “Yes” to certify that the purveyor is in compliance with that “Requirement”
or “No” to certify that the purveyor is not in compliance with that “Requirement” for the current year. For each
“Requirement” in which the purveyor is not in compliance, explain the nature of the non-compliance and what efforts
the PWS is making to return to compliance. Please add additional pages if needed for explanations.
Yes
No
Requirement
Compliance with Federal Safe Drinking Water Regulations
(Title 40, Code of Federal Regulations (40 CFR)
If no, explain the nature of the non-compliance and what efforts your water system is making, as well
as a timeline, for an estimated return to compliance. ______________________________________
________________________________________________________________________________
Compliance with New Jersey Safe Drinking Water Regulations
(N.J.A.C. 7:10)
If no, explain the nature of the non-compliance and what efforts your water system is making, as well
as a timeline, for an estimated return to compliance. _____________________________________
________________________________________________________________________________
Compliance with Licensing of Water Supply and Wastewater Operators
(N.J.S.A. 58:11-64 to 58:11-73 and N.J.A.C. 7:10A)
If no, explain the nature of the non-compliance and what efforts your water system is making, as well
as a timeline, for an estimated return to compliance. _____________________________________
_______________________________________________________________________________
Riverdale Boro Water Department
NJ1433001
2 0025695
2 0025787
DEP_10 S_00001.1
Revised 10/2022
Compliance with Water Supply Allocation Permits
(N.J.A.C. 7:19-6 and 7)
If no, explain the nature of the non-compliance and what efforts your water system is making, as well
as a timeline, for an estimated return to compliance. ______________________________________
________________________________________________________________________________
Compliance with Water Quality Accountability Act
(N.J.S.A. 58:31-1 et seq.)
Section 3: Inspections, testing by water purveyor. (Valves and Hydrants)
Has every fire hydrant in the system been tested in the past year?
Have all the system-owned hydrants been labeled and GPS’d?
Are all valves ≥12” being inspected every four years?
Are all valves <12” being inspected every eight years?
Have all of the valves been GPS’d?
Section 4: Development of cybersecurity system; exemptions
Has your system updated its cybersecurity program in accordance with the 2021 WQAA amendments?
Has your system submitted your cybersecurity program assessment to NJCCIC?
Section 5: Violations; mitigation.
Note: Unless you have otherwise been notified by the Department, this box should be checked “Yes”.
Section 7: Asset Management plan; report.
Has your system submitted its Capital Improvement Report to NJDEP?
Is your system’s asset management plan being implemented?
If no, explain the nature of the non-compliance and what efforts your water system is making, as well
as a timeline, for an estimated return to compliance. ______________________________________
________________________________________________________________________________
I, ____________________________________ am the individual required by the WQAA to certify that my system is
in compliance in the period of time from January 1st, ______________ to _______________, ____________.
(current year)
(date of signing)
(current year)
I have discussed the above materials with the Licensed Operator of record for my system. I certify under penalty of
law that the information provided in this document is true, accurate, and complete. I am aware that there are
significant civil and criminal penalties for submitting false, inaccurate, or incomplete information, including fines and
or imprisonment.
_______________________________________
____________________
Title
Date
____________________________________________________________
Printed Name
_____________________________________________________________
Signature
Paul M. Carelli
2025
12-31-2025
2025
Mayor
Paul M. Carelli
5-14-2026