3900-FM-BSDW0014
Instructions
7/2012
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF SAFE DRINKING WATER
Remove and recycle these instructions prior to mailing to DEP
SPECIAL PERMIT BY RULE FOR WATER VENDING MACHINES
The attached description form has been developed to provide completeness and uniformity in the submission of
information supporting the registration of drinking water vending machines in Pennsylvania. Additional information such as
water quality analyses or manufacturer’s literature should be submitted as attachments.
This form is to be completed by vended water systems which qualify for the special permit by rule requirement under
Section 109.1005(b) of the Department of Environmental Protection (DEP) regulations. The form has been designed on
the basis that:
i.
water vending machines have been approved by a third party such as the National Automatic Merchandising
Association (NAMA).
ii.
water vending machines will obtain their water from a DEP permitted Community Water System (CWS).
iii. water vending machines will be operated within the same DEP Region.
Proposals to install water vending machines not certified by NAMA or on other than an existing permitted CWS will require
the submission of a detailed permit application as outlined in Section 109.1005(d) of DEP’s Safe Drinking Water
Regulations. For this purpose, the appropriate modules from DEP’s Public Water Supply Modules (18-A-B-C and
3900-FM-BSDW0254) must be completed and submitted along with the appropriate plans and specifications.
As a minimum, the following items must be submitted for each permit by rule registration of a vended water system:
1) A registration form (3900-FM-BSDW0063) properly executed by a principal executive officer, general partner or the
owner of the system.
2) A completed copy of the Permit By Rule description form (3900-FM-BSDW0014).
3) An analysis of the quality of the vended water for total coliform, total dissolved solids, lead, and cadmium for each
machine installed for this registration.
4) An Operations and Maintenance Plan which addresses each item in Section 109.1008(b) of DEP’s Safe Drinking
Water Regulations as they relate to water vending machines. In addition, this plan must describe all: In-place
sanitation and servicing procedures; parts replacement and replenishing schedules; operations and shut-off control
settings; and all routine water quality parameters and their frequency; and the backflow preventers testing and
maintenance schedule.
5) An emergency response plan which addresses each item listed in Section 109.1008(e) of DEP’s Safe Drinking Water
Regulations.
6) A registration fee payable to the “Commonwealth of Pennsylvania” in the amount of $300.
7) Copies of the notice to each CWS used as a source by the vended water system.
Duplicate copies of the above information must be submitted to the appropriate regional office.
3900-FM-BSDW0014
7/2012
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF SAFE DRINKING WATER
Date Prepared
PUBLIC WATER SUPPLY
PERMIT BY RULE DESCRIPTION FORM
VENDED WATER SYSTEMS
Date Revised
NOTE:
I.
As a minimum, requests for a special permit by rule registration for a vended water system must contain completed
copies of this description form. The form requests information on the owners of the vended water system and the
emergency contact person in the event a water vending machine needs maintenance or to be taken out of service.
Owners of the system are to notify DEP of any changes in the person to be contacted, or the address or telephone
number used to contact this person. Information about the design and installation of the water vending machines is also
requested. Only one copy of the National Automatic Merchandising Association’s (NAMA) approval needs to be
submitted to cover those machines of the same make and model. Where various makes and/or models are to be
installed, a copy of NAMA’s approval for each make and/or model must be submitted.
VENDED WATER SYSTEM INFORMATION
(Name of System)
(Emergency Contact Person)
(Business Address)
(Address)
(Municipality)
(State)
(Responsible Official)
II.
PERMIT NO. (FOR DEPARTMENT USE ONLY)
(Zip Code)
(Municipality)
(Telephone Number)
(State)
(Telephone Number)
MACHINE INFORMATION
A.
1)
Has more than one make or model of the machine been installed?
Yes
No
2)
Has each vending machine been evaluated and approved by
the National Automatic Merchandising Association (NAMA)?
Yes
No
3)
If yes, include a copy of the approval or certification for each make
and model of machine being installed.
4)
If no, the Permit by Rule does not apply and a separate permit
application as outlined in Section 109.1005(d) of DEP’s
Safe Drinking Water Regulations must be submitted.
5)
Total number of NAMA vending machines installed under this
registration.
6)
Submit detailed specifications for EACH make and model of water
vending machine which describes each process, control switch,
chemical or treatment unit and lists their replacement parts.
1
(Zip Code)
3900-FM-BSDW0014
7/2012
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF SAFE DRINKING WATER
Date Prepared
PUBLIC WATER SUPPLY
PERMIT BY RULE DESCRIPTION FORM
VENDED WATER SYSTEMS
Date Revised
III.
IV.
OPERATIONS AND MAINTENANCE
Has an operations and maintenance plan been developed and enclosed
which addresses the following for each model of water vending machine?
Yes
A.
Machine cleaning and maintenance schedule,
Yes
B.
Sensor and control settings,
Yes
C.
Parts replacement/replenishment schedule,
Yes
D.
Vended water testing (parameters and frequency)
Yes
EMERGENCY RESPONSE
Has an emergency response plan been enclosed which addresses each item
listed in Section 109.1008(e) of DEP’s Safe Drinking Water Regulations?
V.
PERMIT NO. (FOR DEPARTMENT USE ONLY)
Yes
MACHINE LOCATION
Using a separate sheet of 8½ X 11 paper, provide a listing of the following information for each water vending
machine being installed under this registration: machine number, serial number, make & model number, the name
of the CWS connected to and location of installation (street address, city, county).
VI.
INSTALLATION
A.
Has each CWS source been notified of connection to their system?
If yes, has a copy of each letter been attached?
Yes
Yes
No
No
B.
Is the source water system protected from backflow?
Yes
No
C.
Where wastewater is discharged to a sewer, is the waste line
properly air-gapped?
Yes
No
VII. LABELING
Where labeling is used, provide a copy of each label. Also, submit a copy of notice to be posted at each water
vending machine listing recommendations for the care, cleaning and type of container suitable for use with the
water vending machines.
Signature of Vended Water System’s Responsible Official
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Date