Municipal Facilities Forms

List of forms for the Division of Municipal Facilities.

Clean Water State Revolving Fund

Priority List
- CWSRF Questionnaire for Potential Financial Assistance
Loan Application
- Loan Application Packet
Facility Plan
- Cost and Effectiveness Certification
Project Bid
- Bid Document Submittal Checklist
Request for Payment
- Request for Payment Form
Project Close-out
- Final Document Checklist and Forms
- Sample One Year Certification

Drinking Water Program

General
Arsenic Rule
- Arsenic Sample Information Sheet and Sampling Instructions
Consumer Confidence Rule
- CCR 2021 Certification Form (≤ 500 people)
- CCR 2021 Certification Form (501-9,999 people)
- CCR 2021 Certification Form (≥ 10,000 people)
Fluoride Addition
- Fluoride Sample Information Sheet and Operator Value Report Form
Lead & Copper Rule
Nitrate-Nitrite
- Nitrate and Nitrite Sample Information Sheet and Sampling Instructions
- Individual Nitrate/Nitrite Sample Information Sheet and Sampling Instructions
  - (This form is to be used only if the combined nitrate and nitrite level is found to be elevated. Verification should be obtained from the DWP prior to sample collection.)
Operator Certification
Operator Reimbursement
- Operator Reimbursement Form
- IRS W-9 Form
Public Notice Rule
Revised Total Coliform Rule
- Sample Site Plans
  - RTCR Sample Site Plan (≤ 1000 people)
  - RTCR Sample Site Plan (≥ 1001 people)
- Start-up Procedures
  - Seasonal Startup Procedures and Certification
Stage 2 Disinfectants/Disinfection ByProducts Rule
- Chlorine Residual Reporting Form
- Disinfectants and Disinfection ByProducts Rule (DBPR) Summary Form - Stage 2
Surface Water Treatment Rules
- Conventional Treatment
- Membrane Technology

Drinking Water State Revolving Loan Fund

Intended Use Plan/Priority List
- Project Questionnaire for the DWSRF
Loan Application
- Loan Application Packet
Project Bid
- Bid Document Submittal Checklist
Request for Payment
- Request for Payment Form
Project Close-out
- Final Document Checklist and Forms
- Sample One Year Certification

Plan and Specification Review

Drinking Water Design Standards
- Water System Capacity Assessment Manual

Department of Environmental Quality
4201 Normandy Street
Bismarck, ND 58503-1324
P: 701-328-5150
F: 701-328-5200
E: deq@nd.gov

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