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BSDW - 31 Revised 04/02 New Jersey Department of Environmental Protection Page 1 of 1
Water Supply Administration - Bureau of Safe Drinking Water
401 East State Street, P.O. Box 426
Trenton, New Jersey 08625-0426
Tel (609) 292-5550 Fax (609) 292-1654
Annual Water Utilization Report WR
System Name: PWSID #
Address:
City: State: Zip: YEAR
Check here if percentage loss exceeds 15% Check here if percentage loss exceeds 20%
A B C D E F G H I J K L M N
Amount Total Un-
Total Total Total Un-
diverted Amount Amount accountable Total Total Number Total length accounted
amount amount Number of estimated accounted
from own entering the purchased amount used amount of amount of of Un- of Water
Calender entering the used from Metered amount used Water per
surface & distribution from other at metered bulk sales to unaccounted Metered Distribution Percentage
Period distribution recorded connect- at un- mile of
ground system from water connections other water water connect- System of total
system sources ions metered water main
water own sources purveyors (excl bulk purveyors ions water mains supply
connections
sources sales) H/L
B+C E+F D-G 100( H / D)
MG MG MG MG MG MG MG MG MG Miles % gal/mile
Jan - Mar 0.000 0.000 0.000
Apr - June 0.000 0.000 0.000
July - Sept 0.000 0.000 0.000
Oct - Dec 0.000 0.000 0.000
Totals 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0
If loss exceeds 15% record below any specific reason(s) that caused the excessive water loss. E.g. Major Fire
I certify that these reported figures are correct Owner / Adminstrator Licensed Operator
Print Phone # Date
Signature of Licensed Operator or Name
Owner / Administrator This form is available from the DEP web site at http://www.state.nj.us/dep/watersupply
Upon completion this form shall be emailed to watersupply@dep.state.nj.us
