6.1. SR 07-18-2005 - Laserfiche WebLink

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Certification of Completion of Assessment A final step in completing the "Security Vulnerability Self-Assessment Guide for Small Drinking Water Systems Serving Populations Between 3,300 and 10,000" is to notify the Minnesota Department of Health that the assessment has been conducted. Please fill in the following information and send this page only to the appropriate Minnesota Department of Health contact. so that this certification can be included in the records that the state maintains on your water system. · DO NOT send the completed vulnerability assessment (VA) to the Minnesota Department of Health unless your state requires VA submittals. DO send the completed VA to the U.S. EPA Administrator by June 30, 2004 to satisfy the requirements of the Federal Bioterrorism Act. You must also certify to the U.S. EPA Administr~tor that you have developed or updated your emergency response plan based on yourVA within six months of submitting your VA to the U.S. EPA. The Agency will be providing instructions to water systems to follow when submitting your VA and certification. Please follow these U.S. EPA procedures when released. Public Water System (PWS) 10: Number: System Name: Address: Town/City: ZIP Code: Phone: Email: Person Name: Title: Address: Town/City: ZIP Code: Phone: Email: . 171004 Elk River Municipal Utilities 322 King Ave. Elk River State: MN 55330 763-441-2020 Fax: 763-441-8099 Bryan Adams General Manager 322 King Ave. . Elk River State: MN 55330 763-441-2020 Fax: 763-441-8099 24 Hour Emergency Contact Information for Your System: Bryan Contact Person: First Name: Dave Daytime Phone: 763-441-2020 Fax: 763-441-8099 Emergency Phone: 763-441-2020 E-mail: Cell Phone: 612-859-9666 (Adams) 612-845-6190 (Berg) I certify that the information in this vulnerability assessment has been completed to the best of my knowledge and that the appropriate parties have b otified of the assessment and recom ended steps to be taken to enhance the security of the water system. Furthermo ,a copy f the completed asses . el)J will b retained at the pubic water system, in a secure location, for state review as requested ~) ~/. / . / Signed L ) V~ Adams Last Name: Berg 5" - J -C:;...J Date 29