Free 53291.pdf - Indiana

INVENTORY CHANGE
State Form 53291 (6-07)

Indiana Department of Environmental Management (IDEM) Office of Water Quality - Drinking Water Branch - Compliance Section


PWSID #: DATE:





SYSTEM NAME:
s

ACTIVATION POP. CHANGE

RE-ACTIVATION INACTIVATION CONTACT CHANGE NEW POE POE CHANGE SEASON CHANE OTHER

SYSTEM DESCRIPTION (General information describing the public water system)
NEW SYSTEM NAME:
SYSTEM TYPE (C,N, orT): COUNTY: BEGIN DATE: LOCAL HEALTH DEPT: INACTIVATION DATE: DISTRICT:

OPERATIONAL INFORMATION (Detailed information regarding the operating parameters of the system.)
Transient Population: Non-Transient Population: Residential Population:

SOURCE TYPE (G,S, or P): To

SERVICE AREA: SERVICE CONNECTIONS:

OWNER TYPE:

SEASONAL DATES OF OPERATION:

SYSTEM LOCATION (Address giving the physical location of the water system, not necessarily a valid mailing address.)
ADDRESS:
CITY: STATE:

TELEPHONE NUMBER:
ZIP CODE:

OPERATOR INFORMATION (Address & other info. of the individual responsible for operation, maintenance, and sampling.)
ADDRESS: CITY: STATE: ZIP CODE: TELEPHONE NUMBER: ( ) EXT:

OPERATOR NAME (FIRST)

(Last)

CERTIFIED? (Y or N):

GRADE:

CERTIFICATION NUMBER:

MAILING INFORMATION (Address/phone number of the individual responsible for communication with IDEM via mail.)
ADDRESS: CITY: MAILING NAME (First) MAILING TITLE: STATE: EMAIL: ZIP CODE: MR./MS./MRS. (Last) TELEPHONE NUMBER ( ) FAX NUMBER: ( )

BILLING INFORMATION (Address/phone number of the individual responsible for finances and bills.)
ADDRESS: CITY: BILLING NAME (First) BILLING TITLE: STATE: EMAIL: ZIP CODE: MR./MS./MRS. (Last) TELEPHONE NUMBER: ( ) EXT: FAX NUMBER: ( )

OWNER INFORMATION (Address/phone number of the owner or ultimately responsible party.
ADDRESS: CITY: OWNER NAME (First) STATE: ZIP CODE:

This address should be used for VRLs.)

EMAIL:

MR./MS./MRS.

TELEPHONE NUMBER: ( EXT:

)

(Last)

EMERGENCY CONTACT INFORMATION (Information below should be used for infrastructure security only.)
PRIMARY CONTACT PERSON: 24-HOUR TELEPHONE: CELLULAR PHONE NUMBER : PAGER NUMBER: EMAIL ADDRESS:

(Information below should be used for infrastructure security only.) SECONDARY CONTACT PERSON: 24-HOUR TELEPHONE NUMBER: CELLULAR PHONE NUMBER : PAGER NUMBER: EMAIL ADDRESS:

(Information below should be used for infrastructure security only.) LOCAL LAW ENFORCEMENT AGENCY NAME: TELEPHONE NUMBER: LOCAL FIRE DEPARTMENT NAME: TELEPHONE NUMBER :

COMMENTS/REASON FOR CHANGE: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

FIELD SIGNATURE: DATE CHANGED:

COMPLIANCE SIGNATURE: ________________________ CHANGED BY: ____________________________________