Water Report

OFFICE OF INSPECTOR GENERAL
PALM BEACH COUNTY

John A. Carey Inspector General
Inspector General Accredited
“Enhancing Public Trust in Government”
Investigative Report
2024-0006
City of Riviera Beach Failure to
Report Water Contamination
November 18, 2024
Insight – Oversight – Foresight

OFFICE OF INSPECTOR GENERAL
PALM BEACH COUNTY
INVESTIGATIVE REPORT
2024‐0006
John A. Carey Inspector General
Inspector General DATE ISSUED: November 18, 2024 Accredited
“Enhancing Public Trust in Government”

CITY OF RIVIERA BEACH FAILURE TO REPORT WATER CONTAMINATION
SUMMARY
WHAT WE DID Based upon our review of information

regarding the management and
The Palm Beach County Office of operation of the City Utility District and
Inspector General (OIG) reviewed media our initial discussions with the City’s
reports and had subsequent Mayor and the FDOH, the OIG initiated
conversations with the Florida an investigation of the following
Department of Health (FDOH) and the allegation:
Mayor of the City of Riviera Beach,
Florida (City) regarding the City Utility Allegation (1):
Special District (Utility District) staff’s
possible misconduct, mismanagement of City Utility Special District staff failed
the City Utility District, and failure to to comply with required water testing,
ensure compliance with the monitoring, reporting, and public notification
reporting, and public notification protocols, and provided inaccurate or
provisions of the Federal and State Safe misleading information to the FDOH
Drinking Water Acts. and/or the public regarding E.
We found that on at least 130 occasions between January and September 2023,
City Utility District staff failed to report, or adequately supervise other
employees responsible for reporting, water testing results for wells and water
distribution points to the FDOH, as required.
Additionally, City Utility District staff failed to immediately report “present” E.

coli results for Well #14 and a distribution point on Caribbean Boulevard, and
submitted false, altered, and/or misleading test results to the FDOH for Wells
#861 and #862. As a result, Wells #861 and #862 were improperly reactivated for
use as part of the City’s drinking water system.
We also found that on multiple occasions, City Utility District senior staff willfully
ignored, instructed other staff to ignore, or provided misleading information
about the water testing results to the FDOH and the public.
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OFFICE OF INSPECTOR GENERAL 2024-0006
coli/fecal contamination or Total that is free of harmful contaminants and

Coliform contamination. safe for public consumption. Compliance
with applicable regulatory provisions
During this investigation, our office minimizes health risks resulting from poor
regularly coordinated with the FDOH on operating procedures and management.
matters falling within both offices’ Accordingly, public water systems have a
jurisdiction. The OIG identified potential critical duty to hire and retain qualified
violations that contributed to the FDOH’s and knowledgeable staff who are
issuance of Warning Letter WP-085-24 competent to manage the operation and
dated July 22, 2024 and Warning Letter maintenance of water distribution and
WP-134-24 dated October 28, 2024, collection systems.
which are attached to this report as
Appendix 2 and Appendix 3. WHAT WE FOUND
This OIG Report addresses alleged Allegation (1) is supported.

misconduct by City employees; it does
not address matters under the purview We found that City Utility District staff
of the FDOH, such as compliance failed to perform their duties and/or
inspections, enforcement actions, or the failed to adequately supervise the
administration of the public drinking performance of other employees
water systems program. responsible for compliance with the
Federal and State Safe Drinking Water
Our investigation centered on whether Acts.
City Utility District staff failed to
adequately supervise and manage the Specifically, we found that City Utility
City Utility District or sufficiently ensured District staff, on an ongoing and
regulatory requirements were met. systemic basis, failed to follow
required water testing, reporting, and
During our investigation we examined public notification protocols, and on
over ten thousand emails; hundreds of several occasions provided false or
water testing results; and written misleading information to the FDOH
communications between City Utility and the public regarding possible E.
District employees, the FDOH, and coli/fecal contamination or Total
Advanced Innovations, LLC d/b/a Capzer Coliform contamination.
Pharmaceuticals (Capzer). We also
interviewed current and former City Utility District Executive Director
employees of the City Utility District, the Michael Low failed to provide adequate
FDOH, and Capzer. supervision over the City Utility District.
He did not implement adequate internal
Regular and repeat water testing, controls to ensure accurate and complete
accurate reporting of results to the reporting of water testing results to the
FDOH, and compliance with public notice FDOH before or after former City
provisions in the Federal and State Safe Compliance Manager Williams separated
Drinking Water Acts are paramount to from the City Utility District, and did not
ensuring that public water systems ensure that employees within his direct
provide customers with drinking water chain of command were assigned to
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tasks they were both willing and able to As a direct result of the City Utility District
perform. Additionally, he misled the staff’s lack of compliance with required
public, his supervisors, and the FDOH by water testing, reporting, and public
stating, without any regulatory or notification protocols, as well as the
technical basis, that a water sample that staff’s provision of inaccurate, altered, or
tested “present” for Total Coliform at a misleading information to the FDOH
Caribbean Boulevard distribution point and/or the public, the safety of City water
was a “false present.” for public consumption could not be
accurately assessed.
City Utility District Assistant
Executive Director Steven Doyle failed We found sufficient information to
to provide adequate supervision over the warrant referring our findings to the
City Utility District. Mr. Doyle directly FDOH for administrative review and to
supervised key employees, yet did not law enforcement (with copy to the State
take steps to ensure that City Utility Attorney’s Office) for determination of
District staff adhered to water monitoring whether the facts arise to a criminal act
and reporting requirements. under Florida Statutes.
City Utility District Compliance WHAT WE RECOMMEND

Manager Anthony Williams repeatedly
and intentionally failed to report water We make the following
testing results to the FDOH and provided recommendations:
false, altered, or misleading information
to the FDOH regarding Wells #862 and . The City Utility District implement
#861, which resulting in those wells being internal processes and controls requiring
improperly placed in service in the water dual acknowledgment of receipt and
distribution system. review of water sample results from
laboratories prior to submission to the
City Utility District Water Treatment FDOH. This measure aims to minimize
Plant Superintendent Melvin Pinkney the risk of fraudulent reporting; improve
failed to provide adequate supervision timely and appropriate response and
and to ensure that testing results were remediation; and enhance the
reported to the FDOH. He failed to timely transparency, integrity, and reliability of
report fecal contamination results for Well reporting.
#14 and the distribution point at 4822
Caribbean Boulevard. The fecal . The City Utility District institute
contamination test results for Well #14 regular training requirements for all City
and the Caribbean Boulevard distribution Utility District employees relating to the
point should have been immediately rules and regulations for the operation of
reported to the FDOH, and a public boil the City Utility District.
water notice should have been issued.
Instead, the contamination was reported . The City Utility District institute a
weeks later, with no boil water notice policy requiring the creation of a process
issued.1 for resolving complaints regarding the
1As of the November 18, 2024, Mr. Low, Mr. Doyle, Dr. Williams, and Mr. Pinkney have all left City employment. Mr.
Low, Doyle, and Pinkney were all City employees at the time of their OIG interviews.
Page 3 of 86
City Utility District, to include but not The City’s response to our
limited to, a) allegations of violations of recommendations is provided in
City Utility District rules, b) lack of ttachment .
compliance with the Federal and State
Safe Drinking Water Act or other The D was provided a copy of
rules and regulations applicable to our report for comment and its
the operation of the City Utility District response is provided in ttachment .
and the City’s public drinking water
distribution system, and/or c) staff’s Mr. ow’s response is provided in
failure to report accurate information to ttachment C.
the City Utility District Management, the
public, or any oversight authority. Mr. Doyle’s response is provided in
ttachment D.
4. The City take appropriate personnel
action. Dr. illiams’ response, submitted by his
attorney, is provided in ttachment .
Mr. inkney was provided a copy of our

report but did not respond.
Page 4 of 86
BACKGROUND
The City of Riviera Beach
The City was incorporated in 1922. The City Charter was initially
adopted by referendum on April 17, 1973, and subsequently
revised by referendum on March 11, 2008 to create a new,
revised City Charter that generally superseded and replaced
the earlier charter, and which has been amended from time to
time. The City is located along the Atlantic shore of southeast
Florida in Palm Beach County and has a population of
approximately 34,093.
The City operates under the Council-Mayor-Manager form of

government. The City Council is comprised of a mayor and five (5) voting members. The
Council Members are elected to three-year staggered terms and are responsible for the
legislative and policy making authority for the City. The Mayor is head of the City
government for all ceremonial purposes, and is a non-voting council member.
The City Manager is appointed by the City Council and is responsible for the proper
administration of all affairs of the City. The Mayor must report to the City Manager
violations or neglect of duty on the part of employees of the City that may come to the
Mayor’s knowledge, and must report to the City Council all violations and neglect of duty
of any official that may come to the Mayor’s knowledge.
The City of Riviera Beach Utility Special District
The City created the City of Riviera Beach Utility Special District in 2004 pursuant to City
Ordinance No. 2972; Chapter 189, Florida Statutes; and other applicable laws, as a
separate legal entity and special district with the purpose to: (i) acquire2 the City’s utility
facilities, and to make improvements and extensions to such facilities; (ii) construct, own,
improve, expand, operate, manage and maintain the facilities; (iii) provide the most
economic and efficient water, wastewater, and reclaimed water utility services to retail
and bulk service customers; and (iv) make provision for rates, fees, and charges. The
City Utility District’s Policy manual acknowledges that in addition to providing potable
water and/or wastewater service, the City Utility District has the ability to provide fire
protection service to customers.
The City Council members serve as the five (5)

member City Utility District Board of Directors, and the
mayor of the City serves as an ex-officio member. The
City Utility District Charter provides that the City will
provide operating and management personnel to the
City Utility District and that pursuant to an agreement
2 The City Utility District acquired water and wastewater facilities, property, and assets owned by the City.
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between the two entities, the City Clerk, City Finance Director, and City Attorney act as
the City Utility District Clerk, City Utility District Finance Director, and City Utility District
Attorney, respectively. On September 23, 2004, the City Utility District and the City
entered into a Service Agreement establishing that the City would provide a City Utility
District Director.
The City Utility District states on its website that its mission is “[t]o provide safe, reliable
and quality water and wastewater services for our customers.”3 Additionally, the website
states,
The Utility Special District department works daily with city officials and public
health partners to prepare for impacts to our customers. Administration, Water
Treatment Plant, Water Distribution and Wastewater Collection divisions within the
Utility Special District continues to develop Continuity of Operation Plans to ensure
our operations continue in the event of an emergency.
Utilities Administration provides executive oversight and administrative support to

all departments within the Utility Special District so that the Utility functions as a
single, cohesive operation to better serve our customers. It provides personnel
administration and development, records management, and project planning,
funding, and management for all major water and sewer capital improvements.
The Utilities Administration also acts as a liaison with other City departments, as
well as Federal, State, and local organizations and regulatory agencies on all water
and sewer issues.
The Utility Special District’s service area encompasses a wide swath from Silver
Beach Road south to 45th Street and the Florida Turnpike east to the Atlantic
Ocean.
The City provided the OIG with an organizational chart for the City Utility District. The
portion of that chart relevant to this report4 is as follows:
3https://www.rivierabch.com/government/utility
4The pictured organizational chart does not list every position within the City Utility District. Multiple positions that are
not relevant to the matters addressed in this report are not pictured.
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Executive
Director
Assistant
Executive
Director
Compliance Water Plant

Manager Manager
Lab Technicians Water Operators
The City Utility District Water Treatment Facility
The Water Treatment Division of the City

Utility District is responsible for the daily
operation of the City's water system. The
City's drinking water is obtained from raw
water from the East Coast Surficial
aquifers, and pumps this water out of the
ground through 27 ground supply
production wells located throughout the
City and three re-pump stations and
transported to the water treatment5 facility through a network of pipelines. The 27 wells
within the City Utility District distribtion system include Wells #14, #861, #862, and #961.
The current water treatment facility was built in 1958, and was acquired by the City Utility
District after its creation in 2004. Eventually, the City Utility District Board determined a
new treatment facility is needed. In November 2021, the Board selected the Haskell
Company and CDM Smith, Joint Venture (Joint Venture), to replace its water treatment
plant at 800 Blue Heron Blvd. The Joint Venture received a Notice to Proceed on January
18, 2023.
In February 2024, the Joint Venture briefed the City Utility District Board Members on the
Progress Update regarding the Water Treatment Plant Replacement Project and
indicated that the estimated cost of the project could exceed $200 million. During the April
2024 City Utility District meeting, the Joint Venture presented three design concepts
5“Water treatment plant” means those components of a public water system used in collection, treatment, and storage
of water for human consumption. See §403.866, F.S.
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(baseline, 40% over baseline, and 100% over baseline) and estimated that the cost to
complete the entire project for the construction of the water treatment plant at Blue Heron
and Avenue L, drill nine additional supply wells in the surficial and Florida aquifer
systems, and upgrade the distribution system could exceed $300 million.
Florida’s Safe Drinking Water Act Program
Congress originally passed the Federal Safe Drinking Water Act (SDWA) in 1974 to
protect public health by regulating the nation’s public drinking water and its sources—
rivers, lakes, reservoirs, springs, and ground water wells. The United States
Environmental Protection Agency (EPA) administers the SDWA.
The SDWA gives primary responsibility for public water systems6 programs to states to
implement the program. The Florida legislature enacted the Florida Safe Drinking Water
Act (sections 403.850-.864, F.S.), and gave the Florida Department of Environmental
Protection (FDEP) authority to serve as the primary agency responsible for enforcing the
SDWA and authority to adopt and enforce the Florida Safe Drinking Water Act drinking
6 Section 403.852(2), F.S. defines a “public water system” or “PWS” as a system for the provision to the public of water
for human consumption through pipes or other constructed conveyances if such system has at least 15 service
connections or regularly serves at least 25 individuals daily at least 60 days out of the year. A public water system is
either a community water system or a non-community water system. The term “public water system” includes:
(a) Any collection, treatment, storage, and distribution facility or facilities under control of the operator of such system
and used primarily in connection with such system.
(b) Any collection or pretreatment storage facility or facilities not under control of the operator of such system but used
primarily in connection with such system.”
A “community water system” (CWS) means a public water system that serves at least 15 service connections used by
year-round residents or regularly serves at least 25 year-round residents. See §403.852(3), F.S.
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water regulations (Chapters 62-5507, 62-5558, and 62-5609, Florida Administrative Code
(F.A.C.)) that are no less stringent than the SDWA.
The FDEP and the FDOH entered into an Interagency Agreement authorizing the FDOH
to oversee construction and operation of public water systems and to implement the safe
drinking water program under the SDWA and the corresponding Florida Safe Drinking
Water Act in six counties (Hillsborough, Miami-Dade, Palm Beach, Polk, Sarasota, and
Volusia).10
Well
Public water systems can draw from various sources, including surface water (lakes,
rivers, reservoirs) and groundwater through wells. Rule 62-550.200(123), F.A.C. defines
a “well” as follows:
“Well” means any excavation that is drilled, cored, bored, washed, driven, dug,
jetted, or otherwise constructed when the intended use of such excavation is to
conduct ground water from a source bed to the surface, by pumping or natural
flow, when ground water from such excavation is used or is to be used for a public
water supply system.
In 1984, the State of Florida created what is now the Well Surveillance Program to ensure
that potentially contaminated wells are located and tested. The Well Surveillance
Program protects public health by monitoring and identifying threats to the drinking water
supply, ensuring that contaminated sites posing the greatest risk get cleaned up first, and
preventing long-term consumption of contaminated drinking water. The Program is
composed of well surveys, complaint sampling, monitoring areas of concern due to
known contamination, public information, and remediation. The FDOH and FDEP have
responsibility for the Program.
Distribution
Section 403.866(5), Florida Statutes, defines “water distribution system” as those

components of a public water system used in conveying water for human consumption
from the water treatment plant to the consumer's property, including pipes, tanks, pumps,
and other constructed conveyances.
7 Chapter 62-550, F.A.C. sets forth set drinking water standards; monitoring requirement; maximum contaminant levels
(MCLs) and treatment techniques to be met by public water systems; and the testing protocol required for certified
laboratories.
8 Chapter 62-555, F.A.C. sets forth the permitting requirements for public water systems, including the location and
construction of wells and the treatment plant.

9 Chapter 62-560, F.A.C. gives the description of the violations of Chapters 62-550, 62-555, and 62-560, F.A.C. and
resulting penalties and notice requirements.

10 Section 403.862(1)(c), F.S
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The Federal EPA’s website states,11
Drinking water distribution systems connect water treatment plants or water

sources (in the absence of treatment) to customers via a network of pipes, storage
facilities, valves, and pumps. In addition to providing water for domestic use,
distribution systems may supply water for fire protection, agricultural, and
commercial uses. Public water systems are responsible for operating and
maintaining their distribution systems, which extend from the designated entry
point to the distribution system – typically the source or water treatment plant - up
to the service connection, after which the piping is the property owner’s
responsibility.
Distribution systems represent the vast majority of the physical

infrastructure for water systems and serve as the final barrier against
contamination. Distribution systems must be operated and maintained to
reduce the risk of contamination from external sources or internal sources
such as microbial growth or corrosion within the system. [Emphasis added]
Coliforms
Currently, approximately 90 contaminants are regulated under national primary drinking

water regulations established by the EPA. Total coliforms are a group of related bacteria
found in plant material, water, and soil. Coliforms are also present in the digestive tracts
and feces of humans and animals. Most of these bacteria are not harmful to humans. The
EPA considers total coliforms a useful indicator of possible water contamination from
other pathogens. Total coliforms are used to determine the adequacy of water treatment
and the integrity of the distribution system.12
Public water systems must take total coliform bacteria samples at regular intervals at
sites that are representative of water throughout the distribution system and in numbers
proportionate to the population served by the system in accordance with a written
sampling plan that addresses location, timing, frequency, and rotation period.13
If any routine or repeat water sample is total coliform positive or “present,” the system
(i.e., the lab) must further analyze that sample to determine if E. coli are present. Within
24 hours the owner or operator of the system must collect a set of repeat total coliform
samples in the distribution system under the Revised Total Coliform Rule14; additionally,
all groundwater sources must be sampled for E. coli under the Ground Water Rule.
11 https://www.epa.gov/dwreginfo/drinking-water-distribution-system-tools-and-resources
12 https://www.epa.gov/dwreginfo/revised-total-coliform-rule-and-total-coliform-rule
13 Rule 62-550.830, F.A.C.; 40 C.F.R. §141.858
14 The Environmental Protection Agency (EPA) published the Revised Total Coliform Rule (RTCR) in the Federal
Register on February 13, 2013 (78 FR 10269) and minor corrections on February 26, 2014 (79 FR 10665). The RTCR
is the revision to the 1989 Total Coliform Rule (TCR) and is intended to improve public health protection. Florida adopted
the RTCR by Rule 62-550.830, F.A.C.
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E. coli
Escherichia coli (E. coli) is a species of fecal coliform bacteria. Fecal coliform tests are a
more specific indicator of water contamination. E. coli come from the feces of humans
and warm-blooded animals and is considered the best indicator of fecal water
contamination. If E. coli is present, harmful bacteria or other pathogens may also be
present. Not all E. coli make people sick. Some rare types of E. coli, such as O157:H7,
can cause serious illness.15
Public water systems must comply with the maximum contaminant levels (MCL) for E.
coli for water within the system and treatment technique requirements established in 40
C.F.R. Part 141, which is incorporated by reference in Rule 62.550.830, F.A.C.
Laboratory Testing
For the purpose of determining compliance with standards in Chapter 62-550, F.A.C,
water testing samples must be analyzed by a laboratory certified in drinking water by the
FDOH. Analytical results for samples must be reported by the laboratory in a format
specified in Rule 62-550.730, F.A.C. and in accordance with Chapter 62-160, F.A.C., as
reflected below.
15 https://www.cdc.gov/ecoli/about/kinds-of-ecoli.html
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For the purpose of reporting, a result marked “A” means “absent” for a contaminant, and
“P” means “present” for a contaminant.
Training
Water systems must employ or contract with a certified operator16 licensed by the FDEP.
The mission of the Florida Operator Certification Program is to promote public health and
safety by ensuring that all persons working in drinking water and water distribution meet
the highest standards as determined by the rules and regulations of the FDEP under the
guidelines of the EPA. A "Continuing Education Unit" is required at each renewal cycle.
The EPA provides free trainings and webinars for drinking water professionals, public
officials, and anyone interested in gaining knowledge and skills related to compliance
with the Safe Drinking Water Act, Building the Capacity of Drinking Water Systems,
Drinking Water Grant Opportunities, Water Technical Assistance, and more.17
OIG Interview of Rafael Reyes, the FDOH - Environmental Public Health and
Communications Director
Mr. Reyes told the OIG that the FDOH’s drinking water program has full autonomy to
enforce the Federal Safe Drinking Water Act. The City’s water system, as a public water
purveyor, is part of the systems that the FDOH regulates.
Mr. Reyes stated that wells are overseen under the Federal Ground Water rules. Under
those rules, there is a requirement to collect well samples on a monthly basis. The federal
rule requires municipalities to analyze for one of the three fecal indicators: coliphage,
enterococci or E.coli. Most utilities systems analyze for E.coli because of the federal fecal
indicator tests, it is the least expensive method.
If an active well tests “present” for E.coli, the well should be disconnected from the water
distribution system, and a Tier 1 public notice should be issued within 24 hours of finding
out the result. Once the well has been disconnected, the utilities system is then to collect
five additional samples and analyze them. If the contamination still persists, the utilities
system should take corrective action to eliminate any sanitary problems. Mr. Reyes
stated the utilities system can leave the well on and still take the five samples, but if any
of the five samples come back “present,” another Tier 1 public notice would have to be
issued.
In Florida, in addition to the fecal indicator, water systems also have to be analyzed for
Total Coliform. Total Coliform testing details whether there is bacteria present that could
16 Section 403.866(3), F.S. states, “operator” means any person, including the owner, who is in onsite charge of the
actual operation, supervision, and maintenance of a water treatment plant, water distribution system, or domestic
wastewater treatment plant and includes the person in onsite charge of a shift or period of operation during any part of
the day.
17 https://www.epa.gov/dwreginfo/drinking-water-training
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lead to fecal contamination. When a sample is “present” for Total Coliform, any of three
fecal indicators need to be tested for; most systems then test for E.coli.
If an active well tests “present” for Total Coliform, the utilities system has to retest the
well per Chapter 62.555 and 62.550 of the Florida Administrative Code. Those rules state
that a utilities system with a “present” Total Coliform test, must collect two additional
samples from the well within 24 hours. If the well keeps testing present for Total Coliform,
the utilities system should disinfect the well and then start collecting a new bacteriological
survey.
Mr. Reyes stated that for a distribution point to be put back in service after a “present”
Total Coliform sample there needs to be three repeat samples; one at the original site,
one upstream within five connection points, and one downstream within five connection
points.18
If a well has been disconnected for less than six months, a utilities system has to do five
consecutive samples of negative results. If a well has been disconnected for more than
six months, it has to get 10 to 20 consecutive samples of negative results.
These requirements are part of public water systems’ training and detailed
responsibilities. As public water systems notify the FDOH, they should also be working
on a public notice to provide to the FDOH for review, approval, or changes. Boil water
notices depend on the severity of the contamination.
Mr. Reyes stated that the FDOH issues warning letters which state potential violations.
Utility districts have a chance to request a meeting with the FDOH and discuss the validity
of alleged violations. On occasion violators plead ignorance. In that case, there is a
statutory obligation for the FDOH to provide information and guidance to individuals and
that utility district.
Mr. Reyes stated that the term “false present” is not a proper term for E. coli and Total
Coliform tests; the proper term is “invalid sample.” An invalid sample occurs when there
is a second “present” sample at the original site and the other two resampling points are
negative.
OIG Interview of Emmanuel Peters, FDOH Environmental Health Specialist
Mr. Peters told the OIG that any City Utility District employee who collects and submits
bacteriological reports to the FDOH needs to have knowledge of the Florida Department
of Environmental Protection Drinking Water Program and the Federal Safe Drinking Water
Act. Compliance managers, Assistant Directors, and Executive Directors of a utility district
should have knowledge of the Safe Drinking Water Act policies and procedures in order
to run a safe utility district. Mr. Peters stated that he usually provides training and guidance
when he conducts inspections or site surveys at utility districts. He recalls conducting a
18 “Connection points” are usually distinct property addresses.
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site survey for the City Utility District in January 2023 and meeting City Utility District
employees Melvin Pinkney, Anthony Williams, and David Salas.
ALLEGATIONS AND FINDINGS
Allegation (1):
City Utility District staff failed to comply with required water testing, reporting, and
public notification protocols, and provided inaccurate or misleading information to
the FDOH and/or the public regarding E. coli/fecal contamination or Total Coliform
contamination.
Governing Directives:
The governing directives relevant to this report are detailed in full in Appendix 1. The
directives are listed as follows:
Federal “Safe Drinking Water Act:”

Title 40 C.F.R. Ch. 1, Subchapter D, Part 141 National Primary Drinking Water
Regulations.
Subpart A- General
o 40 C.F.R. §141.1 Applicability.
Subpart D- Reporting and Recordkeeping
o 40 C.F.R. §141.31 Reporting requirements
Subpart Q—Public Notification of Drinking Water Violations
o 40 C.F.R § 141.201 General public notification requirements
o 40 C.F.R. §141.202 Tier 1 Public Notice- Form, manner, and frequency of
notice.
o 40 C.F.R. §141.203 Tier 2 Public Notice—Form, manner, and frequency of
notice.
Subpart S—Ground Water Rule
o 40 C.F.R. §141.400 -General requirements and applicability.
o 40 C.F.R. §141.402- Ground Water Source Microbial Monitoring and Analytical
Methods.
o 40 C.F.R. §141.403 Treatment Technique Requirements for Ground Water
Systems.
Subpart Y—Revised Total Coliform Rule
o 40 C.F.R. §141.851 – General.
o 40 C.F.R. § 141.853 - General monitoring requirements for all public water
systems.
o 40 C.F.R. §141.857 Routine monitoring requirements for public water systems
serving more than 1,000 people.
o 40 C.F.R. §141.858 Repeat monitoring and E. coli requirements.
o 40 C.F.R. §141.859 Coliform treatment technique triggers and assessment
requirements for protection against potential fecal contamination.
Florida Safe Drinking Water Act and Implementing Regulations
Page 14 of 86
Part VI. Water Supply; Water Treatment Plants (403.850 to 403.892)

o Section 403.850., F.S.- Short title
o Section 403.853, F.S. – Drinking Water Standards
o Section 403.857, F.S.- Notification of users and regulatory agencies.
Title 62. Department of Environmental Protection

Chapter 62–550. Drinking Water Standards, Monitoring, and Reporting (62–
550.102 to 62–550.830)
o Rule 62-550.102, F.A.C.- Intent and Scope
o Rule 62-550.310, F.A.C.- Primary Drinking Water Standards: Maximum
Contaminant Levels and Maximum Residual Disinfectant Levels.
o Rule 62-550.730, F.A.C.- Reporting Requirements for Public Water Systems
o Rule 62-550.828, F.A.C. – Ground Water Rule.
o Rule 62-550-830, F.A.C. – Revised Total Coliform Rule.
Chapter 62-555, F.A.C.- Permitting, Construction, Operation, and Maintenance of
Public Water Systems (62–555.310 to 62–555.900)
o Rule 62-555.310, F.A.C.- Source and Sitting Requirements for Public Water
Systems.
o Rule 62-555.315- Public Water System Wells—Security; Number; Capacity;
Under the Direct Influence of Surface Water; Control of Copper Pipe Corrosion
and Black Water; and Disinfection and Bacteriological Surveys and
Evaluations.
Chapter 62-560, F.A.C. – Requirements for Public Water Systems that Are Out of
Compliance (62–560.310 to 62–560.700)
o Rule 62-560.310, F.A.C. Violations.
o Rule 62-560.400, F.A.C. - Scope of Drinking Water Public Notification Rules.
o Rule 62-560.410, F.A.C. - Public Notification - Primary Standards.
The FDOH issued multiple warning letters to the City Utility District, including Warning
Letter WP-085-24, dated July 22, 2024 and Warning Letter WP-134-24, dated October
28, 2024, which are attached to this report as Appendix 2 and Appendix 3, noting potential
violations of the Florida and Federal Safe Drinking Water Acts. This OIG Investigative
Report is not a final adjudication of the matters under the jurisdiction of the FDOH.
Instead, this Report addresses our findings relating to alleged mismanagement,
misconduct, and other abuses by individual City or City Utility District employees that
created conditions within the organization that would allow those potential violations to
occur.
Finding:
The information obtained supports the allegation.
We found that City Utility District staff failed to perform their duties and/or failed to
adequately supervise the performance of other employees responsible for compliance
with the Federal and State Safe Drinking Water Acts.
Page 15 of 86
Specifically, City Utility District staff did not comply with required water testing, reporting,
and public notification protocols, and provided inaccurate or misleading information to the
FDOH and/or the public regarding E. coli/fecal contamination or Total Coliform
contamination.
OIG Methodology for Examination of Water Testing Results
During the course of our investigation, the OIG received and compared Drinking Water
Microbial Sample Collection & Laboratory Reporting forms (Water Sample Result
Forms) for the City’s water samples from three sources:
 Business for Advanced Innovations, LLC d/b/a Capzer Pharmaceuticals

(Capzer), a Lake Worth, Florida lab services company entrusted with testing City
water during the time period of this investigation,
 The City Utility District, and
 The FDOH.
The City Utility District is required to routinely test finished19 water for potential
contaminants. Water samples are taken from the entry point to the distribution system
and at various points within the distribution system.
1. City Utility District Lab Technicians collected water samples for testing. Lab
Technician is an entry-level technical position responsible for collecting and
analyzing samples for environmental and monitoring purposes, as required by the
FDOH and the FDEP. Currently, the position requires an associate's degree from
an accredited college or university with major coursework in biology, chemistry, or
a closely related field and six (6) months experience in an environmental laboratory
performing sampling or analysis of drinking water or closely related experience.
The Lab Technicians work under the general supervision of the Compliance
Manger and Water Treatment Superintendent. The Lab Technicians prepare and
complete chain of custody forms for documentation of field analysis, fill out fields
of the Water Sample Result Form to be completed by the sample collector, and
deliver samples to outside laboratories such as Capzer for testing.20
2. Capzer is a laboratory certified by the FDOH (Certificate #E86109601) under the
National Environmental Laboratory Accreditation Program (NELAP). Capzer is
authorized to conduct water testing for detection of Coliform, Total Aerobic
Microbial Count, Total Coliform, Fecal Coliform, and Escherichia coli. Capzer tests
water samples received from the City Utility District, fills out fields on the Water
Sample Result Form that are to be completed by the laboratory (including lab
receipt date and time, analysis date and time, and presence/absence of
contaminants), and provides water testing results to the City Utility District.
19 Rule 62-550.200(45), F.A.C. defines “finished water” as the water that is introduced into the distribution system of a
public water system and is intended for distribution and consumption.
20 On less than ten occasions since 2015, the City USD sent water test samples to a different lab services company.
Analysis of those tests are not relevant to the actions addressed in our investigation.
Page 16 of 86
3. Thereafter, the City Utility District submits the Water Sample Result Form with the
information from the City Utility District and Capzer to the FDOH. The FDOH adds
its notations to the Form in an area titled “DEP/DOH USE ONLY.”
To gauge the City Utility District’s compliance with reporting requirements, the OIG
reviewed and compared the Water Sample Result Forms the OIG received from Capzer,
the City Utility District, and the FDOH for the same dates, times, and sample points. The
objective of the analysis was to evaluate the timeliness and accuracy of and to detect any
irregularities in the reports.
OIG Interview of Lisa Fiedor, Capzer Pharmaceuticals Project Manager
The OIG interviewed Capzer Pharmaceuticals Project Manager Lisa Fiedor. Ms. Fiedor
told the OIG that Capzer started its business in 2011, analyzing water and performing
microbial testing for Total Coliform and E. coli, and started the business relationship with
the City in 2015. She stated that to her knowledge, the City Utility District went elsewhere
for lab services about twice since 2015, but during 2023 solely used Capzer to test
bacteriological samples for Total Coliform and E. coli. Ms. Fiedor is the primary Capzer
contact for the City Utility District.
Ms. Fiedor explained Capzer’s process for testing Utility District samples:
 The City Utility District filled out the sample collection date, time, location, who the
collector was, and whether there was chlorine residual and PH, on the Water
Sample Results Form.
 The term “Distribution Repeat” is used after a test sample fails; the next sample is
then checked on the form as a Distribution Repeat.
 The “Sample Type” code21 on the form can show that the sample collection is not
the first sample, it is a repeat sample from a failure sample.
 The term “Clearance” indicates a two day or five day consecutive clearance for a
well or distribution location.
 The “Sample Collection Date” on the form indicates the date the water sample is
collected by the utility.
 The top right section of the form that contains the “Lab Receipt Date, Time and
Temperature22,” is filled out by Capzer with City Utility District staff present when
samples are dropped off.
 The “Analysis Date & Time” is filled out by Capzer when the water sample analysis
is completed
21 The Water Sample Results Form indicates “Sample type” codes are: D = Distribution (routine compliance), C =
Repeat/Check, R = Raw, N = Entry Point to Distribution, P = Plant Tap, S = Special (clearance, etc.).
22 The Water Sample Results Form contains the term “Sample Preservation,” which indicates whether or not the
samples were on ice and the temperature of the samples.
Page 17 of 86
Ms. Fiedor stated that if a sample was “absent” for Total Coliform or E. coli, Capzer
would write “A” in the appropriate column on the Water Sample Results Form. If E. coli
or Total Coliform was “present” in the water sample, Capzer would write “P” on the
form.
The section labeled “Date and Time PWS notified by lab of present results” details the
date and time Capzer notifies the City Utility District of a “present” result. The notification
is always verbal and sometimes is followed by an email. Capzer processed reports with
a “present” result within two days of the notification, including notification on Saturdays.
Until City Utility District Compliance Manager Anthony Williams left the district in 2023,
Ms. Fiedor sent test results to him, along with City Utility District Water Superintendent
Melvin Pinkney.
Ms. Fiedor stated that she has 100% belief in the accuracy of Capzer’s test methods and
results. Ms. Fiedor is the final form reviewer. When a mistake is made on a form, Ms.
Fiedor crosses out the error, and initials and dates next to the error. A new form would
never be used to correct an error; the original form with the corrected, initialed, dated
mistake will always be used.
A. Staff Failed to Timely Report Test Results
OIG Laboratory Report Analysis
The e amined the entirety of City Utility District water testing laboratory reports from
anuary of through December of . e found that of those laboratory
results, all between anuary and eptember , may not have been reported to the
D within the first ten days following the month in which the result was received, as
re uired in 4 C. . . 4 . a) and ule . ) a), . .C. 4 The identified
potential violations contributed to the D ’s issuance of arning etter 4
dated uly , 4 to iviera each. copy of the arning etter is attached hereto as
ppendi . The D arning etter notes possible violations for failure to report
water testing results. owever, the D notified the that the City Utility District
produced evidence after its arning etter was issued, which resulted in the D
reducing the number of reporting violations to ttachment ). Thus, this report
reflects this additional information.
23 On one additional occasion in December of 2023, the City USD reported a present test for Total Coliform to the
FDOH after its required submission date.
24 In October of 2023, many of these Total Coliform-present reports were submitted, upon Marjorie DeBerry’s
appointment as the new City USD Compliance Manager. This OIG Report discusses in detail the circumstances that
led to the eventual submission of these ‘Presence of Total Coliform’ reports.
25 The EPA generally characterizes Warning Letters as informal enforcement actions.
Page 18 of 86
OIG Interview of Rafael Reyes, FDOH - Environmental Public Health and

Communications Director
During this investigation we regularly communicated with the FDOH and provided them
with records that the City Utility District failed to submit or altered. Mr. Reyes told us that
based on these OIG-provided records, they found additional violations.
Mr. Reyes told the OIG that he has thirty (30) years of experience working with various
health departments throughout the State of Florida. He stated that after Marjorie DeBerry
was appointed the new City Utility District Compliance Manager, Ms. DeBerry provided
documents to him which should have been provided prior to her appointment. After
receiving and reviewing the information and records provided by the OIG prior to Ms.
Deberry’s provision, the FDOH concurred that between January and September of 2023,
the City Utility District did not submit 15126 laboratory test results to the FDOH, as
required. The laboratory tests results that were not sent to the FDOH as required included
lab test results that showed the presence of contaminants as well as results that showed
the absence of any contaminants.
OIG Interview of Swan Allen-Davis, City Utility District Laboratory Technician
The OIG interviewed Swan Allen-Davis, a City Utility District Laboratory Technician. Ms.
Allen-Davis told the OIG that she has worked as a lab technician for the City of Riviera
Beach from November 2022 to present. Ms. Allen-Davis received her Associates of
Science Degree in 2012. Ms. Allen-Davis stated she had “some background” in volatile
organics training, documentation and completion for balances, conversions, calibrations,
on logging water reports, water and soil testing.
26 Per the previous page of this report, the number of non-submitted tests was later established by the FDOH as 130.
Page 19 of 86
Ms. Allen-Davis’ said her duties and responsibilities at the City Utility District include
laboratory calibrations for equipment, monthly sampling the City’s 42 sites within the
distribution system and 27 ground production wells, laboratory drop-offs, special
samplings, and sending samples to the appropriate labs to be tested. Ms. Allen-Davis
explained that all distribution sites and wells are sampled at least once a month and the
testing is spread out over the month. When Lab Techs collect samples, they label a bottle,
disinfect the spigot, collect samples in bottles, bag the samples, and immediately put the
samples on ice. The collected samples are then sent to Capzer. This testing is designed
to detect E. coli and Total Coliform.
She stated that Anthony Williams served as Compliance Manager until June 12, 2023.
According to Ms. Allen-Davis, upon his departure, Dr. Williams told the lab technicians
that Melvin Pinkney would be their supervisor until a new Compliance Manager was
hired. She stated that two days prior to his scheduled departure, Dr. Williams was training
Mr. Salas and Mr. Pinkney on how to send reports to the FDOH. Ms. DeBerry was
appointed Compliance Manager in October 2023.
Ms. Allen-Davis stated when Dr. Williams worked for the City Utility District, Lab Techs
would respond in two different ways to a “present” result for Total Coliform at active
distribution sites. Dr. Williams would either have the lab technicians re-sample the same
sites, or he would have them perform testing within five service connections upstream
and downstream from the sample points for distribution sites only.
Ms. Allen-Davis stated that solely re-sampling the same site was not the correct way of
addressing a “present” test. Ms. Allen-Davis told the OIG that she questioned Dr. Williams
on why he instructed them to do the re-samplings solely at the same sites instead of the
required upstream and downstream testing. In response, Dr. Williams told her that in any
given month the City Utility District could only have a maximum of two “present” test
results at a site for it to be compliance with the FDOH.
Every time Ms. Allen-Davis solely resampled a site without performing the upstream and
downstream testing it was at the direction of Dr. Williams. When Ms. Allen-Davis would
do the resampling on active distribution lines, it would usually retest as “present.” If it
retested “negative,” Dr. Williams would then report it to the FDOH.
Ms. Allen-Davis recalled getting a lot of “presents” for Total Coliform tests results during
her first six months with the City Utility District. Dr. Williams told her they “had to do
something” because they could not keep getting “present” test results.
Ms. Allen-Davis stated that when Well #961 tested “present” for Total Coliform on June
13, 2023 she tested it again on June 14, 2023. Dr. Williams told her to retest before
knowing the results of the prior retest. She stated that the only way for her to know if a
testing she did was “present” was when the Compliance Manager informed her.
Ms. Allen-Davis stated that on numerous occasions an original lab form that showed a
“present” result for Total Coliform would be discarded; Dr. Williams would instruct her to
Page 20 of 86
retest all the sites again that tested “present” for Total Coliform. Often no one would know
when a lab form had a “present” Total Coliform result because only the negative forms
were submitted. Ms. Allen-Davis has reviewed all Capzer lab reports that were submitted
to the FDOH with new Compliance Manager DeBerry. After this review, Ms. Allen-Davis
now believes that during Dr. Williams’ time at the City Utility District only the
absent/negative results were sent to the FDOH for clearance.
Ms. Allen-Davis stated that Ms. DeBerry informed her that re-testing the same site in the
way that Dr. Williams instructed them before should never have been done.
OIG Interview of Melvin Pinkney, City Utility District Water Plant Superintendent
According to the job description for the City Utility District, the Water Plant Superintendent
maintains accurate and detailed plant records; communicates with State, local, and
county agencies to ensure the City Utility District is following all guidelines and rules of
operations; and directs work assignments to make sure they are carried out timely. The
Water Treatment Plant Superintendent must hold a water plant operator’s license.
The OIG interviewed Melvin Pinkney. Mr. Pinkney has been employed with the City Utility
District since 2017. He was a Water Plant Operator until 2021, when he was promoted to
Plant Superintendent. Mr. Pinkney holds a water plant license from the State of Florida,
which qualifies him to be a superintendent or supervisor. He attends yearly training
courses but has not received training on reporting bacteriological lab reports, Total
Coliform reporting rules, or ground water rules.
His responsibilities while employed with the City as a Water Plant Operator included
managing the plant, treating the water to make sure the water was safe to drink,
maintaining chlorine residuals, making sure all of the equipment at the plant worked, and
retaining necessary information. Mr. Pinkney said that since he became the Plant
Superintendent, the Lead Operator, Mr. Salas, has performed all reporting and clerical
duties for Mr. Pinkney.
Mr. Pinkney told the OIG that while employed as the Compliance Manager, Dr. Williams
acted upon any “present” results for main water source lines or wells. When Mr. Pinkney
received test results, he would sometimes look at them, but sometimes he would not. Dr.
Williams communicated with Mr. Pinkney to inform him of wells that had failed or needed
to be shut off. When a well failed during Dr. Williams’ tenure, Dr. Williams notified Mr.
Pinkney, who then had it shut off. The City Utility District then would sample the well again
to see if it would pass.
Mr. Pinkney stated he was not tasked with becoming the interim Compliance Manager
upon Dr. Williams’ departure and was not tasked with reporting to the FDOH at that point.
Mr. Pinkney said that Dr. Williams told him that City Utility District Assistant Director
Steven Doyle and Mr. Salas would be in charge of compliance upon Dr. Williams’
departure.
Page 21 of 86
Mr. Pinkney told the OIG that in June 2023, reports to the FDOH were submitted late due
to Mr. Salas being out on leave. Mr. Pinkney tried to fill in during Mr. Salas’ leave and
sent the reports to the FDOH in Mr. Salas’ absence.
Despite his representation to our office, on July 19, 2023, upon submitting the
Utilities District monthly water testing report to the FDOH, Mr. Pinkney emailed
Mr. Peters of the FDOH and stated “…Mr. Peters please bear with I am doing the
compliance manager position now…”
OIG Interview of David Salas, City Utility District Lead Operator
Mr. Salas told the OIG that he has been the Lead Operator at the City Utility District water
plant since 2007. He has reported to Mr. Pinkney for about six years and acts as a liaison
between Mr. Pinkney and the other water plant operators. Mr. Salas has not received
training in bacteriological reporting rules; those rules are handled by City Utility District
compliance staff.
Mr. Salas stated that the Compliance Manager responds and acts on the monthly Capzer
test results by instructing Mr. Pinkney of the results and of what action to take in order to
make contaminated wells again safe for use. Dr. Williams did not discuss “present” test
results with Mr. Salas; Dr. Williams discussed these things with Mr. Pinkney, who
sometimes then discussed them with Mr. Salas.
Prior to the City Utility District creating a compliance department, Mr. Salas responded to
the FDOH with the City’s test lab results. That changed when Dr. Williams joined the City
as Compliance Manager in 2021. When Dr. Williams left City employment in June of 2023
until the City hired Ms. DeBerry in October 2023, the City Utility District did not have a
Compliance Manager.
Starting on July 7, 2023 Mr. Salas took an approximately two month leave of absence
from his City employment. Mr. Salas has no personal knowledge of who assumed the
role of Compliance Manager for the time period between Dr. Williams leaving and Ms.
DeBerry’s hire. Mr. Salas said that he never assumed the role of interim Compliance
Manager.
Mr. Salas stated that he never had the City Utility District duty of reporting of laboratory
test results after 2021. Mr. Salas stated that he had no knowledge of altered test results
and that he never altered lab results. Mr. Salas stated that he had no knowledge that lab
reports were not submitted as they should have been.
Page 22 of 86
OIG Interview of Dr. Anthony Williams, former City Utility District Compliance
Manager – May 8, 2024
Dr. Williams worked as the Compliance Manager OIG NOTE: At the time of this
for the City Utility District from February of 2021 until first OIG interview of Dr.
June 16, 2023.27 At the time of this interview, he was Williams, the OIG had yet to
working for the City of Delray Beach Water Utilities receive laboratory testing
Department as its Compliance Manager. The Water reports from Capzer.
Utilities Department job description for the
Compliance Manager states that the individual
“under general supervision, creates and leads the District's compliance program to ensure
regulatory requirements for water and sewer operations are met.”
He has a doctorate in public administration and a master’s degree in business

administration. He also received training from University of Florida TREEO28 program on
water cross connections, how to conduct survey inspections, and how to write ordinances.
He told the OIG that his supervisors provided him with rules and regulations relating to
water quality, and he also learned through conferences and job experience.
Dr. Williams provided training to City lab technicians, including field sampling techniques,
aseptic techniques, proper laboratory calibrations, and requirements under Florida
Administrative Code Rules 62-550 and 62-555. He stated that FAC 62-550 covers
standards for primary and secondary contaminants, microbiological testing, reporting
requirements to the FDOH, and record keeping. Dr. Williams also provided lab technicians
at the City Utility District with the rules that govern proper reporting requirements of
“present” Total Coliform and E coli test results.
The City Utility District utilized Capzer to conduct its water lab tests. The City Utility District
sampled 42 drinking water samples a month and all of the wells that were in service.
Mr. Pinkney was the City Utility District Water Plant Superintendent during Dr. Williams’
tenure with the City. According to Dr. Williams, Mr. Pinkney would determine if a well
should stay in service or out of service once it tested “present” for E. coli. If Mr. Pinkney
was not available, Mr. Salas took over plant operations.
Dr. Williams told the OIG that there are two different processes for lab testing and
procedures to take after a “present” E. coli lab test. With drinking water that is going
through distribution systems and customer homes, if there is a “present” E. coli test at a
house or distribution sample, it is necessary to conduct an upstream and downstream
27 According to the City Utility District’s current job description, the Compliance Manger creates and leads the Utility
District’s program to ensure regulatory requirements for water and sewer operation are met, including “ensuring zero
non-compliance with permits and regulations.” During Dr. Williams’ time as Compliance Manager, the job description
stated, “[t]he purpose of this position is to investigate, address and enforce City ordinances and protect the health and
safety of the City’s citizens.”
28 The University of Florida Training, Research and Education for Environmental Occupations (UF TREEO) is the
University’s environmental training center providing certification courses and continuing education for essential
workers. https://treeo.ufl.edu/
Page 23 of 86
sample within five service connections, as well as another test at the original service
location. If the subsequent lab results come back negative after a “present” test, there is
no a need to report anything to the public.
A “present” E. coli test on a ground water well is considered an automatic E. coli violation.
The requirement is then to take five water samples from the well within 24 hours. Dr.
Williams stated that in that circumstance it is necessary to inform the FDOH and the public
(with a public Tier 1 Notification) that there was a “present” E. coli test result. Dr. Williams
stated that a well must be in service and part of the public water distribution system in
order for the notification requirement to take effect. Wells that have been out of service
for more than six months require ten consecutive absent bacteria results for the FDOH to
clear them back into service. The samples can be taken once a day for ten days or two a
day for five days. Dr. Williams stated that if there is one “present” bacteria sample in a
well’s ten day test period, it can still be cleared if the last two samples are negative.
Dr. Williams could not recall any “present” E. coli tests in either the City Utility District
water main distribution system or ground water wells during his employment with the City
Water Utility. Dr. Williams stated the he was responsible for notifying the FDOH of any
“present” E. coli test results. If he was not available, Mr. Pinkney or Mr. Salas had the
notification responsibility.
Mr. Low would also have to be notified of a “present” E. coli test result. Dr. Williams stated
that if there were any instances where present lab results were not provided to the FDOH
it would have been at the direction of Mr. Low. Dr. Williams stated that he tried to change
or add sample locations for retesting but his attempts were shut down by Mr. Low. Dr.
Williams did not expound on specifics of these attempts during this interview.
Dr. Williams said that City Utility District laboratory technician Jasmin Holland was familiar
with the re-sampling rule for E.coli “present” water test results and would perform the
required five service connection upstream and downstream re-samplings.
OIG Re-Interview of Dr. Anthony Williams, former City Water Utility Compliance
Manager – August 13, 2024
After the OIG’s interviewed Dr. Williams in May 2024, our office received copies of the
City Utility District water testing laboratory results for January to December 2023 directly
from Capzer. Our office examined the entirety of the laboratory reports and compared
them with the reports the City Utility submitted to the FDOH for the same period. After the
OIG’s comparison of the reports, we re-interviewed Dr. Williams.
Dr. Williams stated that his listed job duties did not include the reporting of water testing
results to the FDOH; however, he was assigned and performed this task during his time
as City Utility District Compliance Manager, primarily because Mr. Pinkney was not
capable of performing that task. Dr. Williams told the OIG that Capzer emailed him the
test results from the City’s water samples, but that he did not review every single email
because there were so many of them.
Page 24 of 86
Dr. Williams stated that sometimes the City Utility District laboratory technicians would
verbally tell him that the integrity of the samples they took and submitted to Capzer were
in question. Dr. Williams acknowledged that on those occasions, even if those water
sample tested “present” for contaminants by Capzer, he at times would not submit those
samples to the FDOH. Dr. Williams said that he did not document those occasions or
communicate those issues to the FDOH; instead, the “present” samples were never sent
to the FDOH. Dr. Williams stated that he was aware that Capzer or the FDOH could
invalidate samples, but he was not sure whether he was allowed to invalidate samples.
Dr. Williams said that eventually, he told the City Utility District laboratory technicians that
they should notate potentially compromised water samples on the chain of custody forms,
but he was “not sure” if they ever did so.
Dr. Williams stated that at times he would accompany the City Utility District lab
technicians to testing locations to see if they were using proper test taking procedures,
and if he felt the lab technicians were performing their job property, he would have those
samples submitted in their entirety.
Dr. Williams also questioned whether Capzer’s “present” test results were always
accurate. On one occasion, Dr. Williams said that he telephoned Capzer to inquire about
a clearance well that had a succession of “present” Total Coliform tests. Capzer told him
that the tests were accurate.
Dr. Williams does not think that he ever communicated to the FDOH that he failed to
submit “present” water test results on the basis that he worried about the integrity of those
tests. Dr. Williams added that “it probably would have been best to do it that way, to get
their (the FDOH’s) guidance on that.”
When asked “why wouldn’t you just disclose that to them, to the Department of Health?”
Dr. Williams responded “I didn’t, I didn’t know I had to.”
Dr. Williams initially denied only submitting “absent” results for water samples while not
submitting “present” results for water samples as a tactic to open a well or to keep a well
open.
Dr. Williams was asked to assess his responsibility for not reporting “present” test results
to the FDOH:
OIG: At some point somebody's responsible for this and, and you're the compliance
manager.
Dr. Williams: I'm not trying to say that I'm not responsible, but in a lot of these
instances, the results were given to me from the lab tech. It was scanned into the
computer, and after scanning it into the computer, I would formulate the file to send
to the health department by putting all of the different weeks together.
OIG: Would you say you're somewhat responsible?
Page 25 of 86
Dr. Williams: I wouldn't say that.
OIG: You're the compliance manager that deals with this.
Dr. Williams: I understand.

…
Dr. Williams: I don't know if I submitted all of those, so I can't really say.
OIG: But that was your job, was submitting it. You already said that.
Dr. Williams: Well, it wasn't my job. I assumed the responsibility.
OIG: Okay, okay, okay. You assumed the responsibility of submitting these reports
to the Department of Health.
Dr. Williams: Yeah.
OIG: Do you know why you're only submitting negatives and not “presents”? I
mean, this is happening over and over again. I'm not showing just one instance.
Dr. Williams: Not too sure.
Dr. Williams then told the OIG that his process of not sending “present” test results to the
FDOH occurred because of the guidance of City Utility District Director Low and Mr.
Pinkney. Dr. Williams said that Mr. Low did not directly give this direction to him; the
direction came “more from” Mr. Pinkney, who received the direction from Mr. Low. Dr.
Williams stated that Mr. Pinkney gave this direction around the time that Dr. Williams
began reporting test results.
Dr. Williams: I think that they were telling me to do that primarily because of the
condition of the wells and they said it was mostly because the wells, they had a lot
that were out of service and I guess whenever they lose a well, forces them to open
up the interconnect and stuff like that, which would end up costing the city more
money to buy water from Seacoast Utilities. So they were pretty much telling me,
hey, let's make sure we get the [absent]. Let's get the results into the health
department to kind of clear wells so that they can get wells back in service.
OIG: Is that wrong?
Dr. Williams: I was following direction.
OIG: No, but is it wrong? I understand you're following the right direction.
Dr. Williams: Based on the rules, it definitely would be wrong.

…
Page 26 of 86
Dr. Williams: So I really trusted what they were saying, and when they showed me
what the rule says, and they showed me that that's how they typically would do it,
I thought, okay, that's okay. And like I said, when I spoke to the health department,
especially regarding the clearance wells, I spoke to them directly and they [FDOH
employees] told me that regarding the clearance wells because they said that they
didn't need all of those samples; that they needed to see two passing results. Just
make sure that you show them the two passing results because that's what the
requirement was to get it cleared.
OIG: We understand that, but as you can see29, on the same day there was a
“present” and a negative and only the “absent” one, the “present” and an “absent,”
excuse me, and only “absent” ones are being submitted because you wanted the
well to get open. That's what you're telling me. That's correct?
Dr. Williams: That's when the direction was given to me to submit those samples
that way.
…
OIG: You were told to do that by? ... Who in particular?
Dr. Williams: Mr. Pinkney. And he said he got his direction from Mr. Low to prevent
opening the area… just to make sure we get “absent” samples to the health
department. So I didn't hear directly from Mr. Low.
OIG: Did at any point you think that was wrong and maybe you should stop?
Dr. Williams: Yeah.
OIG: Was that maybe a reason why you left?
Dr. Williams: Yeah. A big reason.
OIG Interview of Steven Doyle, former City Utility District Assistant Executive
Director
According to the City Utility District’s job description in effect at the time relevant to this
matter, the Utility District Assistant Director helps relieve the department director of the
day to day technical and supervisor detail work of the assigned divisions, by overseeing
the dealings with the FDEP and the FDOH and ensuring that the water and wastewater
systems and laboratories are operating in compliance with the FDEP guidelines.
29During this portion of the interview, Dr. Williams was examining an OIG spreadsheet detailing the OIG-discovered
151 potential instances of non-reporting of water contamination. That number of non-reporting instances was later re-
established by the FDOH as totaling 130.
Page 27 of 86
Mr. Doyle became the City Utility District Assistant Executive Director in February of
2023.30 He stated that he has no knowledge or training about bacteriological water
sampling or lab reporting because that is not his area of responsibility.
Mr. Doyle stated that as Compliance Manager, Dr. Williams spoke with Mr. Pinkney and
Mr. Salas to coordinate water samplings at wells and main distribution systems. According
to Mr. Doyle, it was Dr. Williams’ responsibility to report any “present” bacteriological lab
reports to the FDOH. Mr. Doyle believes Mr. Pinkney had knowledge of the “present” test
results because the lab would call the operators on a “present” result and the operators
would report to Mr. Pinkney and Dr. Williams.
Mr. Doyle told the OIG that upon Dr. Williams’ departure from City employment, reporting
was late because Mr. Salas was out on leave and Mr. Pinkney was assigned to submit
the City reports to the FDOH, but was not competent to do that job. Mr. Doyle
remembered a conversation with Mr. Low relating to the lab reporting violations that the
FDOH discovered. Mr. Low told Mr. Doyle that he was not surprised because the FDOH
was looking at everything relating to the City Utility District.
OIG Interview of Michael Low, former City Utility District Executive Director
Mr. Low told the OIG that after approximately 15 years with the City of Boynton Beach
Utility District Department, primarily as that department’s Deputy Director, in January of
2021, he began working as a consultant to the City Utility District. In January of 2022, Mr.
Low began his employment at the City Utility District as Executive Director, responsible
for improvement projects and day-to-day operations of the utility.
Mr. Low stated that when he started with the City, the Utility District was “a disaster;” there
were extensive issues, but no action was being taken. He said he identified problems with
wastewater pumping, the condition of the pumping stations, and he saw a report saying
the City Utility District needed $45 million to fix those problems and another $30 million to
fix the City well field. Mr. Low had both weekly and monthly meetings with his managers,
during which they were responsible for disclosing well conditions and “present” tests for
bacteria. Mr. Low added that he hoped that urgent issues of “present” tests would be
brought to his attention immediately, not just during weekly manager meetings. While Mr.
Low expected the managers to bring key issues to his attention, he stated that as
Executive Director he could not monitor routine day-to-day operations. Mr. Low stated
that he expected to be notified of any test results that were “present” for E. coli or Total
Coliform.
Mr. Low stated that Dr. Williams was the employee primarily assigned to reporting to the
FDOH, with Mr. Pinkney and Mr. Salas also occasionally handling that duty. Dr. Williams
left City employment in early June 2023. After Dr. Williams left Mr. Pinkney reported test
results to the FDOH. Mr. Pinkney could delegate that responsibility to Mr. Salas, but
30 Mr. Doyle’s OIG interview took place on August 6, 2024, when he was a City employee. He resigned later in August
of 2024.
Page 28 of 86
ultimately Mr. Pinkney had the responsibility. Additionally, Mr. Low stated that Mr. Salas
went out on leave soon after Dr. Williams departed.
Mr. Low attributed problems with water reporting to poor management by City Utility
District department heads. Mr. Low stated that he did not know how things were run; he
stated he had multiple responsibilities including trying to build a new water plant and he
had managers that were responsible for operations.
Mr. Low stated that Mr. Pinkney did not perform his work up to expectations. Mr. Low
characterized Mr. Pinkney as someone who could keep up with a functioning system, but
not a system that needed improvement. He had conversations with both City Manager
Evans and Mayor Felder about replacing Mr. Pinkney. Nothing came of those
conversations.
Mr. Low stated that he never instructed City Utility District staff to fail to submit present
bacteriological test results, and never instructed City Utility District staff to alter test
results.
OIG Interview of Marjorie DeBerry, Current City Utility District Compliance Manager
Ms. DeBerry stated that on October 9, 2023 she started working as City Utility District
Compliance Manager. Soon thereafter, the FDOH asked the City Utility District if they had
submitted all required reports. Ms. DeBerry requested water test results for the City Utility
District directly from Capzer and reviewed the designated network folder assigned to Dr.
Williams prior to his separation from the City. The files in Dr. Williams’ network folder
appeared to include water testing results Dr. Williams had submitted to the FDOH. Ms.
DeBerry also went on the City’s network system shared folders and downloaded reports
that were submitted to the FDOH.
Ms. DeBerry told the OIG that Ms. Allen-Davis had her own folder because Mr. Pinkney
had instructed her to help with keeping track of the reports. There were reports that Ms.
Allen-Davis had that Ms. DeBerry did not receive from the lab. Ms. DeBerry spoke to Mr.
Low regarding the reports from Ms. Allen-Davis and suggested to Mr. Low that they
contact the lab. Mr. Low agreed with the suggestion. Ms. DeBerry contacted Capzer and
Florida-Spectrum31 laboratories to request a copy of every test report for the period from
January to September 2023. She found that some results that the laboratories sent to the
City Utility District had not been provided to the FDOH. She then suggested to Mr. Low
that the City Utility District report to the FDOH that additional test reports existed; however,
Mr. Low instructed her to wait. She then asked Mr. Doyle’s opinion, and he agreed that
the City should immediately send these previously unreported laboratory test reports to
the FDOH.
Ms. DeBerry submitted these test reports to Mr. Reyes of the FDOH, but she did not
initially tell Mr. Low. Ms. DeBerry said that to keep her from “getting into trouble,” Mr.
31On less than ten occasions during our investigative period, the City used Florida-Spectrum Environmental Services,
Inc. for water testing. None of those tests presented information relevant to the issues examined in this OIG Report.
Page 29 of 86
Reyes independently reached out to Mr. Low requesting the reports. Mr. Low did not ask
Ms. DeBerry whether she had submitted the records to the FDOH.
Ms. DeBerry told the OIG she asked Ms. Allen-Davis why repeat samples were not
collected and sent to the lab. She told Ms. DeBerry that Dr. Williams gave the lab
technicians their instructions. Ms. Allen-Davis also stated that when they got “present”
results from the lab, Dr. Williams instructed them to re-do the whole list again. Thereafter,
he would solely report lab reports with “absent” test results.
B. Well #862- Staff Submitted Altered Test Results and Inaccurate

Information to the FDOH
Well #862 – May 2023 Testing
At the beginning of May 2023, City Well #862 was out of service.
The OIG obtained records showing the City Utility District collected water samples from
Well #862 on 12 occasions (two samples per day on six separate days) from May 2 to 12,
2023, and sent them to Capzer for testing. Capzer Project Manager Lisa Fiedor emailed
the test results for each of these samples to Dr. Williams, Mr. Pinkney, and Utility District
lab technician Jasmin Holland.
The testing for that eleven-day period produced Total Coliform “present” results for ten of
the twelve testing samples, with no two consecutive samples testing “absent,” as required
by Rule 62-555.315(6), F.A.C. The water sample collected at 2:26 PM on May 2 tested
“present” for E. coli, and the other eleven samples tested “absent” for E. coli.
Well #862 Test Results – May 2023

Did City Utility Timely
E. coli Test
Date Time Total Coliform Test Result Submit Test Results to
Result
the FDOH?
5/2/2023 8:52 AM Present Absent No
5/2/2023 2:26 PM Present Present No
5/8/2023 9:11 AM Present Absent No
5/8/2023 3:01 PM Present Absent No
5/9/2023 8:27 AM Present Absent Yes
Present altered to reflect no
5/9/2023 1:55 PM Absent No
entry
5/10/2023 3:12 PM Absent Absent Yes
5/11/2023 1:27 PM Present altered to Absent Absent Yes
5/12/2023 8:05 AM Absent Absent Yes
5/12/2023 2:24 PM Present Absent No
Page 30 of 86
Well #862 – May 9, 2023 Testing
According to the Water Sample Results Form prepared by Capzer that the OIG received
directly from the lab, the City Water Utility collected water samples at Well #862 in the
morning and afternoon on May 9, 2023 (at 8:27 am and at 1:55 pm). The Water Sample
Results Forms also included the results for Well #96132 and Well #922. On both
occasions, Well #862 tested “present” for Total Coliform and “absent” for E. coli.
32 There is no evidence that Well 961 was inappropriately returned to service.
Page 31 of 86
However, Dr. Williams sent an email to the FDOH on June 5, 2023, which included
an altered version of the Water Sample Results Form for the samples collected in
the afternoon on May 9, 2023, in that the results for the sample collection at Well
#862 at 1:55 p.m. had been completely removed and not reported. (Additionally, the
Results for Well #961 were also missing from the Water Sample Results Form. However,
Well #961 was not returned to service.) Instead, the form submitted to the FDOH only
included the “absent” for Total Coliform and E. coli results for the water sample collected
at Well #922 at 2:15 p.m.
Page 32 of 86
With the exception of the information about the results for the sample points collected in
the afternoon on May 9, 2023, all other content and notations reflected on the version of
the Water Sample Results forms Capzer sent to Dr. Williams and the version that Dr.
Williams sent to the FDOH were identical, including the following words: “Date and time
PWS notified by lab of present test results: “05/10/23, 2:15p.” (indicated by green
circle on above illustration).
The City Utility Districted collected water samples from Well #862 at 9:08 a.m. and 3:12
p.m. on May 10, 2023. According to the Water Sample Results the OIG received from
Capzer, the morning sample tested “present” for Total Coliform and “absent” for E. coli,
and the afternoon sample tested “absent” for both Total Coliform and E. coli.
According to Water Sample Results the OIG received from Capzer, the following day, on
May 11, 2023, the City Utility District collected water samples from City Well #862 at 8:50
a.m. and 1:27 p.m. Both samples tested “present” for total coliform and “absent” for
Page 33 of 80
E. coli. On May 12, 2023, Capzer emailed the results to Dr. Williams, Mr. Pinkney, and
Ms. Holland.
Page 34 of 86
The May 12, 2023 water sample collected at 8:05 a.m. at Well #862 tested “absent” for
both Total Coliform and E. coli, but again tested “present” for Total Coliform at 2:24 p.m.
on May 12. Despite the two May 11 “present” results for Total Coliform and the afternoon
“present” result on May 12, on Saturday, May 13, 2023, Compliance Manager Williams
emailed the FDOH at their designated agency reporting email address, with Mr. Pinkney
and Mr. Salas copied, the following:
“Riviera Beach Utility Special District (PWS 4501229) received confirmation from
our laboratory that Well #862 has passed the required 2-day consecutive testing.”
Dr. Williams did not attach any test results to this May 13 email. As of that date, Dr.
Williams was fully aware that Well #862 had not tested “absent” for Total Coliform
on two consecutive occasions from May 2 to May 12.
On Tuesday, May 16, 2023, the FDOH Environmental Specialist II Emmanuel Peters
responded to Dr. Williams’ May 13 email, stating “Good afternoon Anthony, You may
place those wells33 back into service based on the successful bact results.”
As a result, Well #862 was placed back in service within the water distribution
system.
Review of the City Utility’s Network Folders

33In Dr. Williams’ May 13 email, he also submitted results of Well #922. The OIG does not question the absence of
contamination in that well.
Page 35 of 86
At the OIG’s request, the City Information Technology (IT) Department searched the entire
City network system to determine whether the May 11, 2023 test results for Well #862
that Capzer email to Dr. Williams, Mr. Pinkney, and Ms. Holland had been saved in any
location.
The City’s IT staff determined that the result for the water samples collected on May 11
had been saved in a shared network folder and in Dr. Williams’ assigned employee-
specific network folder. A review of Dr. Williams’s employee-specific network folder
showed that on May 23, 2023 at 9:16 a.m., Dr. Williams saved the two May 11 (8:50 a.m.
and 1:27 p.m.) Water Sample Results for Well #862. Additionally, Dr. Williams saved the
test results from the water sample collected at Well #862 at 1:55 p.m. on May 9.
The City’s IT staff did not find the May 11 test results on any employee-specific network
folder other than Dr. Williams’. Based upon the information the OIG received and
reviewed, Dr. Williams is the only City employee who saved the May 11, 2023 Capzer
test results for Well #862 to an employee-specific network folder. The only other City
accounts that were able to access Dr. Williams’ employee-specific network folder were
the City IT Administrators.
On June 5, 2023, Dr. Williams emailed an altered version of the May 11 afternoon (1:27
p.m.) test results to the FDOH, along with test result for the morning (8:05 a.m.) of May
12. The May 12 test result Dr. Williams sent to the FDOH is the same document Capzer
emailed to Dr. Williams, Mr. Pinkney, and Ms. Holland reflecting that the sample was
“absent” for Total Coliform. However, the May 11 afternoon test result differed from the
document Capzer emailed to Dr. Williams, Mr. Pinkney, and Ms. Holland, in that the result
of “present” for Total Coliform had been altered to “absent.” Had Dr. Williams submitted
accurate versions of the results from Capzer, Well #862 could not have been reactivated.
The City’s IT staff determined that the altered version of this report was not located on the
City’s shared network drive.
Our office provided the FDOH copies of the May water testing results showing the results
Dr. Williams received from Capzer differed from those submitted to the FDOH. As a result,
the FDOH issued Warning Letter WP-134-24 dated October 28, 2024, to the City Utility
District. Warning Letter WP-134-24 is attached hereto as Appendix 3.__
OIG Interview of Keith Hampshire, City Information Technology Department

Systems Administrator
Mr. Hampshire stated that he can determine when a file on the City’s network was
originally saved and when or whether it was modified.
The document identified by the OIG as the May 11, 2023 water test results from Capzer
Laboratory was originally saved in the City shared system on May 12, 2023, with the name
Clearance_Well_862.pdf. A document with the same name was saved in then-City
employee Anthony Williams' employee-specific City network folder at
Page 36 of 86
"E:\Home\ACWilliams\Lab Compliance\1-Monthly BacT" at approximately 9:16:40 am on

May 23, 2023.
The same document was modified and re-saved in Dr. Williams' same employee-specific
City network folder on May 23, 2023 at 9:18:37 am.
The OIG examined screen shots of activity in the drive assigned to Dr. Williams. At 9:18
a.m. on May 23, 2023, Dr. Williams modified and then re-saved the May 2023 Capzer test
result document:
In addition to the results from the water sample collected on May 9 with all information
regarding Well #862, including the “present” for Total Coliform result removed, Dr.
Williams also sent for the first time on June 5, 2023, the purported Capzer test results for
water samples collected from Well #862 on May 11 at 1:27 p.m. and May 12 at 8:05 a.m.
Although the documentation the OIG received directly from Capzer-- which Capzer had
sent to and Dr. Williams received -- showed the samples tested “present” for Total
Coliform, the document Dr. Williams sent to the FDOH reflected “absent” for Total
Coliform:
Page 37 of 86
The OIG’s review of the lab results attached to Dr. Williams’ June 5 email to the FDOH
and the lab results Capzer sent to him regarding the results of the water samples collected
on May 11 showed:
 The results form Capzer prepared and sent to Dr. Williams for the water samples
collected on May 11, 8:50 a.m. that showed “present” for Total Coliform was not
attached to the email. Based upon a review of Dr. Williams’ emails and the
documents our office received from the FDOH and Capzer, it does not appear that
Dr. Williams ever sent this test result to the FDOH during his tenure at the City
Utility District.
 The results form Capzer prepared and sent to Dr. Williams for the water sample
collected on May 11 at 1:27 p.m. that showed “present” for Total Coliform was not
attached to the email. Instead, “present” result for Total Coliform had been altered
to “absent.” (see red circle on above illustration)
Page 38 of 86
Below the altered “absent” for Total Coliform results for the collection at 1:27 p.m.
on May 11, appear the following words: “Date and time PWS notified by lab of
present test results: “05/12/23, 2:25p.” (see green circle on above illustration)
The following OIG graphic details a timeline of the conveyance of information and the
altered report sent for the clearance of Well #862:
OIG Interview of Melvin Pinkney, City Utility District Water Treatment Plant
Superintendent
The OIG showed Mr. Pinkney the email from Capzer to Dr. Williams and cc’ing him with
the results from the water sample collected from Well #862 on May 11, 2023, and the
June 5, 2023 email from Dr. Williams to the FDOH which also cc’d Mr. Pinkney. Mr.
Pinkney told the OIG that he did not alter the Well #862 test results, and he does not
know who may have altered them.
Mr. Pinkney stated that he did not notice that the City Utility District may have sent an
altered report, and he never discussed the reports with Dr. Williams.
Page 39 of 86
OIG Interview of Dr. Anthony Williams, former Compliance Manager for City Utility
District– May 8, 2024
The OIG showed Dr. Williams the Capzer form

reflecting “present” for Total Coliform and E. coli for OIG NOTE: At the time of this
the water sample taken for City Well #862 on May first interview of Dr. Williams,
2, 2023 at 2:26 p.m. Dr. Williams stated that Well the OIG had yet to receive
#862 was an out of service well at that time, and laboratory testing reports
therefore not part of the City water distribution from Capzer which included
system. Dr. Williams did not recall if he notified the the altered test report.
FDOH about the “present” E. coli test results for the
sample collected from Well #862 on May 2.
The OIG showed Dr. Williams the email from him to the FDOH dated June 5, 2023
attaching test results for samples collected on May 11th and 12th, 2023. He stated this
email is similar to emails sent by him to the FDOH on a monthly basis relating to monthly
lab test reports.
OIG Re-interview of Dr. Anthony Williams, former Compliance Manager for City
Utility District – August 13, 2024
The OIG showed Dr. Williams:

 The documents we received directly from Capzer indicating that the sample
collected on May 11, 2023 at Well #862 tested “present” for Total Coliform;
 An email from Capzer dated May 12 to him with the May 11 test results showing
“present” for Total Coliform;
 The May 13 email that he sent to the FDOH requesting that Well #862 be put
back in service with a notation the City Utility District “received
confirmation….that Well #862 has passed the required 2-day consecutive
testing”;
 Information showing that the Water Testing Results forms with the results he
received on May 12, 2023 from Capzer were saved and modified on his
employee-specific folder on the City’s network on May 23, 2023; and
 The June 5 email from his City email address to the FDOH that included a
version of the May 11 test result that differed from the results he received from
Capzer in that he emailed a document purporting to show that Well #862 had
tested “absent” for Total Coliform.
Dr. Williams told the OIG that he probably did not open the May 12 email from Capzer
containing the “present” for Total Coliform test result for the May 11 sample. He then
stated that by the time he emailed the FDOH asking to reopen Well #862 on May 13, one
of the laboratory technicians “must have” altered the May 11 Capzer test result and
provided him with the altered version via a paper copy, which he would have scanned and
saved. Ms. Holland was the senior laboratory technician at the time, and Dr. Williams
stated that she “likely” brought the May 11 test results to him. He said that would explain
why he emailed the altered version to the FDOH on June 5. Dr. Williams stated that he
Page 40 of 86
does not necessarily compare what the lab technicians tell him and show him with the
results attached to the emails Capzer sent to him.
Dr. Williams believes that on May 23, 2023, he saved the paper version potentially
provided to him by Ms. Holland and sent it to the FDOH on June 5. Dr. Williams stated
that he has never altered water testing records and has never had discussions with
anyone about altering water testing result records. Dr. Williams stated that Ms. Holland
became very disgruntled at some point during her employment with the City.
OIG Re-interview of Jasmin Holland, City Utility District Laboratory Technician –

August 28, 2024
Ms. Holland stated that as a practice she opened testing results sent to her via email from
the lab. She would then discuss the results of those opened lab results with Dr.
Williams. She does recall hand delivering hard copies of lab results to Dr. Williams. This
was done on rare occasions when she was not able to reach him via email or phone. The
normal process was to advise Dr. Williams by call, text, or in-person that the lab results
had arrived.
Ms. Holland stated she has notified Dr. Williams that a lab result may possibly have been
“present” when she believed that rain or another contaminant affected the test
sample. There also were instances during her samplings when she felt the lab did not
practice proper aseptic techniques to perform lab samplings. For instance, there have
been a few occasions when she dropped off samples at the lab and noticed lab staff not
using gloves to receive or handle the samples, and she noticed lab staff not knowing how
to properly take the temperature of the samples. She brought this to the attention of Dr.
Williams.
Ms. Holland stated that she never omitted “present” lab testing results from Dr. Williams.
Ms. Holland stated that she never altered lab results, either on her own or under someone
else’s direction.
OIG Re-interview of Swan Allen-Davis, City Utility District Laboratory Technician –

August 28, 2024
Ms. Allen-Davis stated she only began to receive completed lab reports via email from
Capzer in the middle of August 2023. Mr. Pinkney, Mr. Salas and Mr. Low also received
lab reports via email at that time. Ms. Allen-Davis recalled that Mr. Pinkney took over lab
reporting duties when Dr. Williams resigned. Mr. Pinkney wanted Ms. Allen-Davis to
submit the completed lab reports to the FDOH, but she felt uncomfortable doing this and
she told Mr. Pinkney she would not. She collected the lab reports sent to her via email
and stored them in a folder for Mr. Pinkney to review. Mr. Pinkney then reviewed and sent
them to the FDOH. Ms. Allen-Davis never submitted hard copies of completed lab reports
to Dr. Williams.
Page 41 of 86
Ms. Allen- Davis stated that she never omitted “present” lab reports for Dr. Williams.
Ms. Allen-Davis told the OIG that she never altered lab results and never received
instruction from others to alter lab reports.
C. Well #861- Staff Submitted Inaccurate Information to the FDOH
Well #861 – March, 2023 Testing
On March 17, 2023, the City Utility District collected a water sample from City Well #861
at 9:20 a.m. and sent it to Capzer for testing. Capzer Pharmaceuticals Project Manager
Lisa Fiedor sent the Water Sample Results to Dr. Williams, Mr. Pinkney, and Ms. Holland.
According to the documents Capzer provided directly to the OIG, Well #861 tested
“present” for Total Coliform and “absent” for E. coli. Capzer notified the City Utility District
of the results on March 20, 2023.
Page 42 of 86
Well #861 was out of service on the March 17 sample collection date; therefore Well #861
needed two consecutive tests reflecting “absent” for Total Coliform and E.coli before it
could be returned to operational service.
Per Capzer test results received by the FDOH, the City Utility District re-tested Well #861
later that same day at 1:46 pm. This time, Well #861 tested “absent” for Total Coliform
and E. coli.
This “absent” test for Total Coliform fulfilled only the first of two consecutive absent tests
required to bring Well #861 back into service. Nevertheless, on March 18, 2023 Dr.
Williams emailed the FDOH at its designated agency reporting email address, with Mr.
Pinkney and Mr. Salas copied and stated:
Riviera Beach Utility Special District (PWS 4501229) received confirmation from
our laboratory that Well #861 in our wellfield has passed the required 2-day
consecutive testing. The well has been out of service less than 6-months. Would
the Department clear this well for service? Results will be sent in once received.
Page 43 of 86
However, according to Utilities District well logs, on March 15 and March 16, 2023, prior
to this notification to the FDOH, Well 861 was placed back into service. Thereafter, City
Utility District logs detail that Well 861 again closed from March 17 through March 21,
2023, and re-opened thereafter.
On Monday, April 3, 2023, Dr. Williams emailed to the FDOH test results for Well #861,
which included “absent” test results for Total Coliform and E. coli for March 16, and for
Total Coliform and E. coli for the water sample collected at 1:46 p.m. on March 17. Dr.
Williams did not attach the intervening Water Sample Results for the sample collected
from City Well #861 on March 17 at 9:20 a.m., which showed “present” for Total Coliform.
OIG Re-interview of Dr. Anthony Williams, former City Utility District Compliance
Manager – August 13, 2024
The OIG questioned Dr. Williams regarding his submission and omission from his email
to the FDOH of results for samples collected from Well #861 on March 16 and March 17,
2023. Dr. Williams stated that he sent only the “absent” test results and not the “present”
test result because of how he was “trained to do things as far as submitting results.” When
asked, Dr. Williams stated that if he had included the “present” result from the
sample collected at 9:20 a.m. on March 17, 2023, “I pretty much, I assume they
would not” clear the well. When asked if this was the right way to do things, Dr.
Williams responded “No, it isn’t because this is not obviously appropriate if they’re
calling it a violation.”
Dr. Williams added:
So during this time frame, this, in the month of March, this was one of those times
where to, where we were having a very hard time with keeping wells in service and
the inter-connect was obviously gonna be a big thing. So this is where that pressure
did come on as well.
…
So again, I was directed to a part of the rule that says that when it comes to wells
that were not in their original integrity or something, I can't explain how the rule
explains it, word for word, but it pretty much says that if the wells are not in service,
you don't have to submit everything.
…
OIG: So you omitted the present one and you gave the absent? You see what I'm
saying?
Dr. Williams: Yes, I do see what you're saying. Yes, I'm doing what I was told to
do, though.
OIG: If the health department sees that you have a present, you're going to have
to restart all over again. So you can't pick and choose which consecutive days you
Page 44 of 86
want to pick. I mean, now reflecting back, I think you realize that it's wrong what
you were doing.
Dr. Williams: Yes. But again, this is what I was told to do. You know, this is the
instruction that I was given because the wells were out of service. They were afraid
that they would have to open up the inter-connect and the condition of the wells
was so bad that we couldn't afford to lose any more wells. So this is what I was
told to do.
D. Distribution Point at 4822 Caribbean Boulevard – Staff Failed to Properly

Repeat Test and Issue Notice to Public34
June 2023 Testing
In May of 2023, City Utility District Laboratory Technician Allen-Davis went to a location
within the City to obtain a water sample for submission for testing. She noticed a man
staring at her, who then walked into his house and walked out with a gun in pocket.35 City
Utility District staff discussed the incident with the City Police Department. On May 17,
2023, City Assistant Police Chief Michael Madden emailed Mr. Low and Mr. Doyle with
the email subject title “Safety Concerns with staff.” The email from Assistant Chief Madden
stated:
As a follow-up to today (sic) meeting, I am providing some recommendation that

UD may want to consider and/or do additional research:
1. Training For Employees that test water at residences (likely similar to meter
reader training)
2. Review industry standards for PPE for employees who test water at residences
(likely similar to meter reader PPE)
a. PPE for situations they may encounter like angry residents, snakes, wild
animals, dogs, insects, etc.
3. Consider removing residential properties from the testing list
4. Consider revisiting the notification frequency for impact properties, to include
neighbors
5. Consider highly visible markings on vehicles and/or A-Frame signs that state
“Water Testing in Progress”
6. Examine the documents signed by those establishing water accounts to
consider language that states that water testing may occur (language to address
the 5 minutes of running water and walking on private property to access spigot
attached to the house).
34 On July 31, 2024, the City Utility District and the FDOH entered into a settlement of the matters relating to the failure
to collect repeat samples Caribbean Boulevard water distribution point and Well #14 and the failure to provide public
notice, in violation of 40 C.F.R. Part 141, Subparts Q, S, and Y.
35 This incident did not occur at 4822 Caribbean Boulevard.
Page 45 of 86
Additionally, Officers responded and met with your employees to take an incident
report. A copy will be provided once complete.
Let me know if you need additional information.

Thank you
The following month, on June 7, 2023, Capzer notified the City Utility District of the
analysis of water samples City Utility District Laboratory Technician Ms. Holland had
collected at 8:58 a.m. on June 6 at 4822 Caribbean Boulevard. The samples came back
“present” for both E. coli and Total Coliform:
Then, on June 8, 2023, Ms. Holland collected new water samples at 4822 Caribbean Blvd.
at 9:03 a.m. and sent them to Capzer for testing. Although the June 8 samples constituted
a re-test of the Caribbean Blvd. distribution point, Ms. Holland indicated the reason for
sampling as “Distribution Routine” on the Water Sample Result Form (Report No. COL-
Page 46 of 86
W23-117). Ms. Holland told the OIG the checked box signified that this test result applied
only to the original sample location; not upstream nor downstream samples. The June 8
samples from the original location for Caribbean Blvd. tested “absent” for both Total
Coliform and E. coli.
Mr. Pinkney sent this June 8 re-test of the original distribution point, along with all the
June test results, to the FDOH on July 18, 2023.
The OIG was not provided with any Water Sample Result Forms from the City Utility
District, Capzer, or the FDOH indicating that water samples from upstream or downstream
had been collected and tested, as required by 40 C.F.R. §141.853.
On July 24, 2023 the FDOH sent Warning Letter WP-125-23 to the City Utility District, in
which the FDOH inquired about the June 6 “present” test and the June 8 re-test showing
“absent” for Total Coliform and E. coli at 4822 Caribbean Boulevard the FDOH received
on July 18. Mr. Low did not respond to the FDOH until September 11, 2023. He emailed
the FDOH Environmental Consultant-Enforcement Coordinator Pamela Lape (and cc’d
Mr. Doyle and Assistant City Manager Deirdre Jacobs), stating:
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As you can note from the report the Utility Special District (Utility District) did in fact
respond immediately to the finding at SP #3836 on June 6, 2023 and immediately
ordered a recheck. This sample point had not exhibited any issues prior to this
result and the residuals in the system were good. Due to an incident where lab
technicians had felt threatened by a resident when sampling from a home a
program had been started to replace sample points at residential locations.
…
…In conclusion it is the Utility District’s position that we did take immediate action
to check the result following the adverse finding and that the recheck confirmed
that it had been a “false present.”37 Due to the problems sampling at individual
homes the entire area was rechecked immediately and no problems were found.
Later on September 11, 2023, Ewa Kudella-Leczynski, former Water Programs

Manager38 with the FDOH responded via email, stating:
If Riviera Beach Utility provides us with an additional information proving that the
repeat samples collected 06-08-2023 were upstream and downstream of the
original TC+/Fl+ within five service connections, we may accept it.
On September 29, 2023 Mr. Low emailed Ms. Kudella-Leczynski and stated:
To clarify our position with regards to the resampling please note as follows. Due
to threats when sampling at locations not normally used, as would be the case if
the District were to try and sample within 5 service connections you proscribe, we
instead immediately resampled the location that had the adverse result and also
regular sampling stations on either side. All the samples were clear suggesting that
the original was a “false present.” On that basis we did not issue a Tier 1 notice.
Going forward there is a problem in trying to conform to the rule without potentially
risking the employees undertaking the sampling. We have a documented case in
which our lab technicians felt threatened by an armed citizen who was questioning
their presence at a home trying to get a supplemental sample…
On October 2, 2023, Mr. Low emailed Ms. Kudella-Leczynski and resubmitted the Water
Sample Report for June 8, 2023, as what he described as “the corrected resample lab
report for the June 6, 2023 retest as requested by your office.” On this “corrected” Water
Sample Report (Report No. COL-W23-117) for June 8, the box under “Reason for
Sampling,” which is checked by the sample collector, now contained a whited-out check
box for “Distribution Routine,” and a checked box for “Distribution Repeat.” The original
36 On the Capzer Water Sample Result Form, SP #38 is the test site at 4822 Caribbean Blvd.
37 During his interview with the OIG, Mr. Reyes of the FDOH told our office that the term “false present” is not a proper
term for E. coli and Total Coliform tests; the proper term is “invalid sample.” Additionally, Mr. Low pointed to no
regulatory or technical basis for such a conclusion. Indeed, the term “false present” does not appear in applicable
regulations, neither Capzer nor the FDOH invalided the samples, and Mr. Low did not ensure that the sample point was
tested upstream or downstream in order to support his position.
38 Ms. Kudella-Leczynski no longer works with the FDOH. She is an environmental engineer.
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Water Sample Report (Report No. COL-W23-117) and “corrected” Water Sample Report
(Report No. COL-W23-117) had the same report number; sample collection dates, times,
and sample points; lab receipt date and time, analysis date and time, and information in
the fields to be completed by the laboratory. The only change was to the “Reason for
Sampling” box.
OIG Interview of Lisa Fiedor, Capzer Pharmaceuticals Project Manager
The OIG showed Ms. Fiedor the Capzer laboratory report form with sample collection date
June 6, 2023, showing test results as present for both Total Coliform and E.coli, and the
original laboratory report with the sample collection date of June 8, 2023 that is checked
as a “Distribution Routine” under the “Reason for Sampling” section and showing 4822
Caribbean Boulevard as absent for both Total Coliform and E. coli.
Finally, the OIG showed Ms. Fiedor the October 2, 2023 email Mr. Low sent to the FDOH
attaching what he described as “the corrected resample” lab report results for the sample
collected date of June 8, 2023.
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Ms. Fiedor stated after the lab results were done by Capzer, the City was not supposed
to make any changes to the form. Ms. Fiedor explained if there were any changes made
to that form by Capzer, those would have been attached with the original in the FDOH’s
files. In this case, she did not believe Capzer made any changes to the 4822 Caribbean
Boulevard report form.
OIG Interview of Eva Kudella-Leczynski, former FDOH Water Programs Manager
The OIG showed Ms. Kudella-Leczynski an email dated October 2, 2023, where Michael
Low attached a “corrected” Water Sample Form showing the retest on June 8, 2023 at
the same location (4822 Caribbean Boulevard) with the “Reason for Sampling” section
marked as “Distribution Repeat.” The OIG also showed Ms. Kudella-Leczynski the June
6, 2023 “present” result from Capzer marked “Distribution Routine.”
The OIG asked Ms. Kudella-Leczynski whether it would be a violation if a document was
altered to say it was a “Distribution Repeat” and not a “Distribution Routine.” She stated
that doing so could have been an honest mistake considering Dr. Williams was about to
leave the City Utility District and the main operator was on leave. She also
stated someone should have initialed the change or made a note of the change. Ms.
Kudella-Leczynski stated she would give the utilities system the benefit of the doubt and
discuss who made the mistake with them. However, she also stated that whiting out the
lab section and altering the form would raise questions about the form. Ms. Kudella-
Leczynski then told the OIG that under proper protocol, only Capzer can correct a lab
report. Ms. Kudella-Leczynski considers it a violation if the lab was not aware of the white-
out change.
She explained it is important for the FDOH to know if the upstream was present in the
repeat sample because that is how they know that there is a problem above the sampling
point.
OIG Interview of Emmanuel Peters, FDOH Environmental Health Specialist
Mr. Peters stated that the bacteriological samples for the distribution point at 4822
Caribbean Boulevard tested “present” for both E. coli and Total Coliform in June 6, 2023.
By not conducting the repeat samples, this distribution system had an acute maximum
contaminant violation. This required notification within 24 hours by the City Utility District
to the FDOH about the present E. coli test and a public boil water notice.
Mr. Peters stated that Total Coliform test samples for 4822 Caribbean Boulevard were
taken intermittently in June 2023 and had to be reported to the FDOH by July 10, 2023.
However, the City Utility District submitted the June 2023 bacteriological reports on July
18, 2023, and only then after the FDOH requested they be submitted. After these present
Total Coliform samples, the City Utility District had to collect three samples; upstream and
downstream within five connections, and at the sample site. The City Utility District never
took the repeat samples as required.
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OIG Interview of Jasmin Holland, City Utility District Laboratory Technician
Ms. Holland stated that the City Utility District tested 4822 Caribbean Boulevard as part
of regular monthly testing. She reviewed a laboratory form dated June 6, 2023 for 4822
Caribbean Boulevard, and stated that the site tested “present” for Total Coliform and E
coli on that date.
Ms. Holland said that if a test came back “present,” there needed to be an upstream test
within five connections, a downstream test within five connections, and a repeat sample
point test. Performing all three of these tests constituted a “Distribution Repeat.”
Ms. Holland stated that she never performed the required distribution repeat in June of
2023 for 4822 Caribbean Boulevard. Ms. Holland explained that she was told by Dr.
Williams that they could solely resample the sample site, without performing the required
upstream and downstream testing. According to Ms. Holland, Dr. Williams told her to list
the June 8 tests as a “Distribution Routine” test; the accurate description of the test that
solely had the test of 4822 Caribbean Boulevard, not the upstream or downstream tests.
Ms. Holland was shown the June 8 sampling for 4822 Caribbean Boulevard that listed the
reason for sampling reclassified to “Distribution Repeat,” with the original “Distribution
Routine” checked box whited out. Ms. Holland stated that sampling documentations are
considered official documents. If there were any changes to the sampling documentation,
the error would be scratched out and accompanied with the person’s name, date and the
reason for the change. Ms. Holland stated that a form changed to “Distribution Repeat”
by whiting out the true version would be considered a falsified document in her opinion.
OIG Interview of Swan Allen-Davis, City Utility District Laboratory Technician
On one occasion Ms. Allen-Davis said that she and Ms. Holland were out in the field when
Ms. Allen-Davis noticed a man staring at her, and then walked into his house and walked
out with a gun in pocket. Ms. Allen-Davis and Ms. Holland left the area without further
incident. Ms. Holland wrote an email about the incident and sent it to the City Utility District
Safety Coordinator and Risk Manager; Dr. Williams was not at the office at the time. Ms.
Allen-Davis and Ms. Holland also had an in-person meeting with City Safety Coordinator
Solomon Burgess, Risk Manager Steve Shields and Mr. Doyle. During that meeting it was
agreed that the lab technicians were thereafter to go as a pair to collect samplings.
Dr. Williams was aware of this safety incident; he was copied on the email to the Safety
Coordinator and Risk Manager. After the incident, Dr. Williams informed the lab
technicians that they were not to go out as a pair to collect samples. Dr. Williams told Ms.
Allen-Davis and Ms. Holland that his hands were tied due to the Assistant City Manager
stating that working in pairs would decrease productivity. Routes were not changed for
their safety.
Page 51 of 86
OIG Interview of Steven Doyle, former City Utility District Assistant Executive
Director
Mr. Doyle recalled that two City Utility District lab technicians encountered a safety issue
while conducting water sampling collection; there was a customer at a testing site that
showed them a handgun. Ms. Allen-Davis wanted to test with Ms. Holland thereafter, but
the City Utility District decided against it because safety concerns could also be satisfied
by a lab technician accompanied by a City Utility District operator or with a police escort.
Mr. Doyle did not believe that a safety issue had anything to do with the lab technicians
not properly doing the required testing after the June 6, 2023 present E. coli test at 4822
Caribbean Boulevard.
Manager
Dr. Williams was shown the present E Coli test result for 4822 Caribbean Boulevard water
lab testing site that was collected on June 6, 2023. Dr. Williams stated that during this
time he was transitioning to leave the City Utility District and he programmed lab test
related calls to go to voicemail. All of the direction that lab technicians were receiving
came from Mr. Doyle at that time. He said that earlier in 2023, Ms. Holland and Ms. Davis-
Allen encountered a safety issue while conducting water sampling collection. Ms. Holland
and Ms. Davis-Allen felt unsafe because there was a customer at a testing site that
showed them a handgun. The City Police Department recommended that the lab
technicians should work together to collect water samples. Dr. Williams stated that the
Utility District did not have the resources to collect water samples if the lab technicians
worked as a pair, and he and Mr. Low felt the lab technicians should continue to work
separately for efficiency. The lab technicians did not like this idea. Dr. Williams stated he
was not familiar with the present E. coli test at 4822 Caribbean Boulevard in June of 2023.
OIG Interview of Michael Low, former City Utility District Executive Director
Mr. Low stated he first heard of a problem with 4822 Caribbean Boulevard test results
when he received a FDOH Warning Letter WP-125-23 on July 29, 2023. He immediately
told Assistant City Manager Deirdre Jacobs, and conferred with Mr. Doyle for a meeting
with the FDOH in early September 2023.
Mr. Low recalled a safety issue with the City Utility District lab technicians prior to the
failed Caribbean Boulevard test, during which a resident was armed with a gun and “a
little aggressive” during a test. Subsequently, City Utility District staff met with and
received input from the City Police Department, with Police Department recommendations
provided to increase lab technician safety. Mr. Low could not remember which, if any of
the police recommendations were implemented.
Mr. Low stated that because of this incident there was more of an attempt to go back to
the water main so that they would not have to test at secondary sample points as
frequently, but Mr. Low added:
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…though if you get the hit of course you have to be within five connections here at
the side and they've updated the rule so that now your sampling plan is supposed
to clearly identify which are the secondary sample points if you have a hit at your
main sample point.
Mr. Low stated that he knew that the City Utility District failed to follow the testing protocol
for failed test resamples at 4822 Caribbean Boulevard. He knew that the City Utility District
was required to sample within five points upstream and downstream, but did not. Mr. Low
said that he responded to the warning letter by stating that the proper re-testing was not
performed because of safety concerns and because Mr. Doyle told Mr. Low that he did
an investigation and found that to be the reasoning for not performing the proper re-
sampling.
E. Well #14 – Staff Failed to Properly Notify the FDOH of Testing Results or
Issue Notice to Public
June 2023 Testing
On June 27, 2023, Capzer test results showed that at 9:22 a.m. in-service City Well #14
tested as contaminated with E. coli: the City Utility District did not notify the FDOH nor the
public within 24 hours, as required in 40 C.F.R. § 141.201.
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Approximately three weeks later, on July 18, 2023, Mr. Pinkney attached the June 27,
2023 “present” E. coli test result as part of the monthly “City of Riviera Beach Utilities,
Bacteriologicals, 6-2023” email to the FDOH.
Manager
Dr. Williams stated that Mr. Pinkney called and emailed him after Dr. Williams left City
employment in July of 2023 to ask what needed to be done about the Well #14 present
E. coli test results from June of 2023. Dr. Williams stated he first became aware about
Well #14’s “present” test upon this July email and phone call. The email that Dr. Williams
sent to Mr. Pinkney is dated July 20, 2023 and states:
Mr. Pinkney,
Without knowing the details or seeing official results, from the sound of it, Well #14
had a fecal indicator hit, which means it showed the presence of E. coli. So that’s
why she was asking for the 5 additional samples. This is a requirement under the
Ground Water Rule. Also be mindful that public notice is required for a hit like this
as Tier 1. This is what the rule states:
According to FAC 62-550.518(10), “If fecal coliform or E. coli is present in any

routine distribution system sample or if E. coli is present in any raw water sample
that is representative of a well previously considered to be meeting the
bacteriological requirements in paragraph 62-555.315(6), F.A.C., the system shall
notify the appropriate Department of Environmental Protection (DEP) District Office
or appropriate Approved County Health Department (ACHD) by the end of the day
that the system learns of the test result unless the system learns of the result after
the appropriate DEP District Office or appropriate ACHD is closed, in which case
the system shall notify the appropriate DEP District Office or appropriate ACHD
before the end of the next business day.”
OIG Interview of Melvin Pinkney, City Utility District Water Treatment Plant
Superintendent
Mr. Pinkney remembered seeing the June 27, 2023 test results report for Well #14. In
June, he shut the well off and informed Mr. Doyle and Mr. Low; however, he stated that
the failed test result was not reported within the required 24 hours. Mr. Pinkney stated he
was not responsible for correcting issues in City Utility District reporting to the FDOH or
the public; it was the responsibility of senior management.
OIG Interview of Michael Low, Former City Utility District Executive Director
The first time Mr. Low stated he heard of a problem with Well #14 test results was when
he received a FDOH warning letter on July 29, 2023. Mr. Low told the OIG that he
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described this non-reporting as a “false present” because E. coli in the water distribution
system would be unlikely to have shown up in just one spot.
February 2024 On-Camera Interview of Michael Low, former City Utility District
Executive Director
In February of 2024 WPTV News interviewed Mr. Low on-camera regarding the July 29,
2023 FDOH warning letter. The interview was broadcast to the public. When the reporter
asked “Why didn’t you, though, notify people in Riviera Beach immediately?”
Mr. Low responded “Because there was no need because we have a treatment plant here.
… So we followed all the rules that they asked us to follow.”
Interviews of City Senior Management
OIG Interview of Deirdre Jacobs, Assistant City Manager
Ms. Jacobs has been the Assistant City Manager since before 2023 through the present.
Ms. Jacobs oversees the City Utility District. When he was Utility District Executive
Director, Mr. Low reported directly to her; however, Mr. Low frequently conferred directly
with Mr. Evans, bypassing Ms. Jacobs. Ms. Jacobs stated that because she was Mr.
Low’s direct supervisor, he should have reported problems directly to her, but he did not.
She first heard of issues with the City Utility District in September of 2023, when an
employee that worked in a different City department told Ms. Jacobs that the City Utility
District was trying to hide problems with the FDOH. Ms. Jacobs emailed Mr. Low, asking
him if there were problems with the FDOH. He minimized the problems, telling her that
the water had no issues and any issues with the FDOH were being corrected. At that
point, Mr. Low informed Ms. Jacobs that he was responding to a FDOH warning letter.
Mr. Low told her that staffing issues at the FDOH had contributed to these problems.
In December of 2023 the City Utility District staff met with the FDOH; Ms. Jacobs and City
Manager Evans did not attend the meeting. Afterward, Ms. Jacobs found out that Mr. Low
did not attend the meeting, and therefore she and Mr. Evans resolved that they needed
to learn more. The two of them set up a January meeting with the FDOH to learn about
potential problems. Ms. Jacobs learned that the City had a well that tested present for E.
coli, but that the City did not report the problem in a timely and accurate matter. Mr. Low
told Ms. Jacobs that the steps that the City took had “cancelled out” the present test and
that it was not really a present test, but the FDOH disagreed, telling the City that it failed
to take the proper steps to rectify the problem.
At that point Ms. Jacobs knew that the City had “present” tests for E. coli and Total
Coliform, but still did not know the procedures for reporting. Ms. Jacobs stated that staff
should have informed her and Mr. Evans about those problems; she stated that the
provision of water is the most essential and critical of basic services that the City provides
to the public.
Page 55 of 86
In August of 2024, Mr. Doyle first disclosed to Mr. Evans that test results submitted to the
FDOH were altered by the City Utility District. That is when Ms. Jacobs learned of this
issue, and when Ms. Jacobs learned about non-reporting of test results. Ms. Jacobs had
no personal knowledge about who could have altered test results. She called Dr. Williams
after hearing this and asked him how this could have happened. Dr. Williams told her he
did not alter any test result documents.
Ms. Jacobs stated that she had no indication from staff in any way that the City Utility
District would not be following testing protocols because of safety concerns.
Ms. Jacobs believed that upon Dr. Williams’ departure from City employment, Mr. Doyle
and Mr. Low would have been tasked with supervising compliance.
OIG Interview of Jonathan Evans, City Manager
Mr. Evans became the City Manager in 2019 and currently holds that position. He stated
that Assistant City Manager Jacobs directly reports to him as the Assistant City Manager
over infrastructure, and she oversees the City Utility District. Mr. Evans has an in-person
meeting with City departments heads, including the Executive Director of the Utility
District, every two weeks. During those meetings department heads are supposed to brief
Mr. Evans about keys issues affecting their departments.
Mr. Low briefed Mr. Evans about some operational challenges maintaining the water plant
infrastructure, but never gave Mr. Evans a sense of dire problems with the water
infrastructure. Until he first heard about the FDOH issues with Well #14 and another well
in approximately December 2023, Mr. Low never told Mr. Evans that the City bought water
from other facilities to deliver enough clean water. Mr. Evans stated that he absolutely
should have been informed about these things; because of the fiscal impact of needing
to purchase water and for repairs, because Mr. Low also did not tell Mr. Evans that there
were difficulties with water quality until then, and because Mr. Evans has a duty to brief
elected officials of matters of critical importance. Mr. Evans considers knowledge of issues
with City well water quality to be critical and absolutely something he should have known
about. When these issues first arose in December of 2023, Mr. Low and Mr. Doyle were
“very dismissive” of the importance of the FDOH’s concerns.
In December 2023, Mr. Low characterized the FDOH’s problems with the City Utility
District as based on what he described as “moot” issues such as staff turnover, and that
they were all solvable issues. When Mr. Evans heard about these issues he was upset
that he was not informed sooner. In early 2024 Mr. Evans, Mr. Low, Mr. Doyle, Mr.
Pinkney, Ms. DeBerry, Councilperson Lawson, and Mayor Felder discussed the City
Utility District problems detailed by the FDOH. During this meeting Mr. Evans asked Mr.
Low point blank if the water ever had E. coli or if the public water supply was ever
compromised, and Mr. Low unequivocally said “no.” When the media started to report
about potential problems, Mr. Evans told Mr. Low that if Mr. Low felt that the media and
the FDOH portrayed potential problems inaccurately, it was Mr. Low’s responsibility to re-
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assure the public and let them know that there were not problems. Mr. Low thereafter
made public statements that contradicted the problems that had been publicly detailed.
After the reported information about Well #14, Caribbean Blvd and Well #961, the FDOH
and Mr. Evans, Ms. Jacobs, Mr. Low, Mr. Doyle, Ms. DeBerry, and Mr. Pinkney scheduled
a meeting. On the way to the meeting, Mr. Low called Mr. Evans, stating that the meeting
needed to be cancelled because they found “more stuff.” Mr. Evans and Ms. Jacobs
nevertheless went to the meeting, but no City Utility District staff went to the meeting. At
that meeting the FDOH gave Mr. Evans and Ms. Jacobs information about non-reporting
issues for the first time.
Mr. Evans stated that in approximately May 2023, Mr. Low and Mr. Doyle told Mr. Evans
that a Utility District laboratory technician had seen a man with a firearm while performing
her work duties. Mr. Evans told them that they should get police department assistance if
that happens and that employee safety was critically important. During this discussion, no
one mentioned or suggested deviating from water testing protocol.
In August 2024, Mr. Evans first heard from the FDOH that test results may have been
altered by City Utility District staff to change contaminated test results to passing test
results. Immediately after that meeting, Mr. Doyle brought what he felt was an altered test
result to Mr. Evans. Mr. Doyle resigned during that meeting. A few days later, Ms. DeBerry
notified Mr. Evans in an email of a second potentially altered test result.
Mr. Evans has never heard indications from any City Utility District staff that the private
testing labs used by the City have been flawed in any way.
Mr. Evans believes that City Utility District management did not provide proper oversight
of the City’s day-to-day water supply operations. Multiple City Utility District staffers told
Mr. Evans that Mr. Low and Mr. Doyle were rarely or never present on-site at the City’s
water plant.
Mr. Evans told the OIG that he and his family live in Riviera Beach and they drink and
bathe in the City water supply. He considers the potable water supply to be the most
important resource that the City has.
Conclusion
Congress passed the Safe Drinking Water Act of 1974 after nationwide studies of
community water systems revealed widespread water quality problems and health risks
resulting from poor operating procedures, inadequate facilities, and uneven management
of public water supplies in communities of all sizes. The management and operation of
public water systems is highly regulated through federal and state rules that provide for
regular water testing, monitoring, recordkeeping, and reporting, as well as, industry
certification standards for those who operate water systems and test and collect water
samples.
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The City Utility District’s adherence to governing provisions, accurate and complete
reporting of water conditions to the FDOH, and adequate management of its water
distributions system is paramount to ensure that it provides clean water to its customers
that is safe for consumption. Without that adequate testing and accurate reporting, the
FDOH cannot reliably assess water quality. Additionally, hiring, training, and retaining
competent, well-trained staff is fundamentally and critically important to protecting the
health, safety, and welfare of families residing within the City.
Based upon our review of the relevant documents and interviews, we find that senior
City Utility District staff violated reporting rules, both through mismanagement of
required processes and at times, through deliberate actions designed to
circumvent required accurate reporting of water conditions. Accordingly, the City
Utility District failed to uphold the standards of care entrusted to it by the public
with regard to management and reporting.
Both Mr. Low and Mr. Doyle mismanaged the City Utility District. They supervised the
compliance process, and they both failed in their supervisory duties by not ensuring
accurate and complete reporting of water conditions, and by not assigning employees to
those tasks that were willing and able to ensure full compliance.
Mr. Low stated that when he started with the City, the Utility District was “a disaster.”
Despite believing the district was a “disaster” and having both weekly and monthly
meetings with his managers, Mr. Low stated that he “did not know how things were run.”
He did not implement adequate internal controls to ensure accurate and complete
reporting of water testing results to the FDOH.
He indicated that initially, his Compliance Manager, Dr. Williams was responsible for
notifying the FDOH of “present” test results. After Dr. Williams left, Mr. Pinkney was tasked
with providing results to the FDOH. However, City Utility District staff, including Dr.
Williams and Mr. Pinkney failed to submit required water test results to the FDOH, even
though extensive training had been provided which communicated the necessity of those
submissions. An OIG examination of records found at least 151 occasions of non-
reporting from January through September of 2023. According to one employee, when
Dr. Williams left the utility, Mr. Low personally told her to “wait” before reporting to the
FDOH that some samples had been collected and tested but not reported, as required.
Even after the date Mr. Low contends he personally learned of a “present” for Total
Coliform result on Caribbean Boulevard, he did not take appropriate action. Without any
regulatory or technical basis, he told the FDOH that result was a “false present.”
Additionally, he justified the City Utility District’s failure to properly retest due to safety
issues that occurred weeks earlier. However, those safety issues were addressed with an
appropriate, professional response from the City Police Department, and in any event, at
no time concurrent with that non-testing did Mr. Low (or any City staff) get input that would
have allowed them to deviate from required testing.
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When asked by WPTV why he did not notify the residents of Riviera Beach of the “present”
for E. coli result for Well #14, Mr. Low responded “Because there was no need because
we have a treatment plant here. … So we followed all the rules that they asked us to
follow.”
Additionally, even though Mr. Low became aware of non-reporting of well conditions in
October of 2023, he assured his superior, City Manager Evans, that issues stemmed from
staff turnover and “false presents.”
Mr. Low also told the OIG that after Dr. Williams left the City, Mr. Pinkney was responsible
for the important role of reporting water test results to the FDOH, even though Mr. Low
believed Mr. Pinkney did not perform his work to expectations and asked the City Manager
to replace him. Mr. Pinkney was promoted to Superintendent although Mr. Low, Dr.
Williams, and Mr. Doyle questioned his competency during their interviews with our office.
Mr. Pinkney was copied on test results from Capzer, but Mr. Pinkney said he “would
sometimes look at them, but sometimes he would not.” Once Mr. Pinkney assumed the
role of reporting to the FDOH, he failed to timely report the results for City Well #14 and
issue a boil water notice. Instead the results were reported weeks later and with no boil
water notice issued. Mr. Pinkney reached out to his predecessor, Dr. Williams, only after
being informed by the FDOH that required 24 hour notice for Well #14 had been
mishandled. Of note, even after Mr. Pinkney discovered the non-reporting of
contamination of Well #14, the instances of non-reporting under his oversight continued.
Former Compliance Manager Dr. Williams admitted to deliberate non-reporting during his
tenure. He stated that he knew the rules and did not follow them, attributing his non-
compliance to unspoken pressure from his superiors. When asked about his systemic
non-reporting of test results that revealed the presence of Total Coliform, Dr. Williams told
the OIG that “Based on the rules, it definitely would be wrong.”
Additionally, Dr. Williams, in admitting that water conditions were systemically

misreported to the FDOH, attributed that misreporting to “pressure” that he believed
originated from Mr. Low.
The most egregious example of Dr. Williams’ inaccurate reporting centered on the
alterations of Total Coliform presence in the test results for Well #862. We find that Dr.
Williams received those test results, emailed the FDOH the next day to return that well to
service without including those Total Coliform test results, copied the test result
documents to his City employee-specific network folder, and modified the document, only
to email altered test results to the FDOH weeks later. Moreover, it is indisputable that Dr.
Williams not only provided the altered test results, but also failed to send a Total Coliform-
present test result from the day after the altered test result. If reported by Dr. Williams as
required, that subsequent test result also would have mandated that Well #862 not be
returned to service.
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Mr. Doyle directly supervised Dr. Williams and Mr. Pinkney, and did not take steps to
ensure that his staff performed with integrity and adherence to water testing reporting
requirements.
We find that the City Utility District did not live up to its mission statement “To
provide safe, reliable and quality water and wastewater services for our
customers.”
The allegation is supported.
ACKNOWLEDGEMENT
The Inspector General’s Investigations Division would like to thank the Florida
Department of Health and the elected officials and staff of the City of Riviera Beach for
their cooperation throughout this investigation.
RECOMMENDED CORRECTIVE ACTIONS
The OIG makes the following recommendations:
1. The City Utility District implement internal processes and controls requiring dual
acknowledgment of receipt and review of water sample results from laboratories
prior to submission to the FDOH. This measure aims to minimize the risk of
fraudulent reporting; improve timely and appropriate response and remediation;
and enhance the transparency, integrity, and reliability of reporting.
2. The City Utility District institute regular training requirements for all City Utility
District employees relating to the rules and regulations for the operation of the City
Utility District.
3. The City Utility District institute a policy requiring the creation of a process for
resolving complaints regarding the Utility District, to include but not limited to, a)
allegations of violations of Utility District rules, b) lack of compliance with the
Federal and State Safe Drinking Water Act or other rules and regulations
applicable to the operation of the City Utility District and the City’s public drinking
water distribution system, and/or c) staff’s failure to report accurate information to
the City Utility Management, the public, or any oversight authority.
4. The City take appropriate personnel action.
RESPONSE FROM THE CITY
Pursuant to Article XII, Section 2-427 of the Palm Beach County Code, the City was
provided the opportunity to submit a written explanation or rebuttal to the finding as stated
Page 60 of 86
in this Investigative Report within ten (10) calendar days. Their written response is
Attachment A in this report.
RESPONSE FROM THE FLORIDA DEPARTMENT OF HEALTH
Pursuant to Article XII, Section 2-427 of the Palm Beach County Code, the FDOH was
in this Investigative Report within ten (10) calendar days. Their written response is
Attachment B in this report.
RESPONSE FROM MR. LOW

Pursuant to Article XII, Section 2-427 of the Palm Beach County Code, Mr. Low was
in the Investigative Report within ten (10) calendar days. His written response is
Attachment C in this report.
RESPONSE FROM MR. DOYLE
Pursuant to Article XII, Section 2-427 of the Palm Beach County Code, Mr. Doyle was
Attachment D in this report.
RESPONSE FROM DR. WILLIAMS
Pursuant to Article XII, Section 2-427 of the Palm Beach County Code, Dr. Williams was
Attachment E in this report.
RESPONSE FROM MR. PINKNEY
Pursuant to Article XII, Section 2-427 of the Palm Beach County Code, Mr. Pinkney was
in the Investigative Report within ten (10) calendar days. Mr. Pinkney did not submit a
response.
Page 61 of 86
APPENDIX 1
Federal “Safe Drinking Water Act”
Title 40 C.F.R. Ch. 1, Subchapter D, Part 141 National Primary Drinking Water
Regulations
….
Subpart A- General
40 C.F.R. §141.1 Applicability.
This part establishes primary drinking water regulations pursuant to section 1412 of the
Public Health Service Act, as amended by the Safe Drinking Water Act (Pub.L. 93–523);
and related regulations applicable to public water systems.
….
Subpart D- Reporting and Recordkeeping

40 C.F.R. §141.31 Reporting requirements.
(a) Except where a shorter period is specified in this part, the supplier of water
shall report to the State the results of any test measurement or analysis required
by this part within
(1) The first ten days following the month in which the result is received,…
….
(b) Except where a different reporting period is specified in this part, the supplier
of water must report to the State within 48 hours the failure to comply with any
national primary drinking water regulation (including failure to comply with
monitoring requirements) set forth in this part.
….
[Emphasis added]
Subpart Q—Public Notification of Drinking Water Violations
40 C.F.R. § 141.201 General public notification requirements.
….
(a) Who must give public notice? Each owner or operator of a public water
system … must give notice for all violations of national primary drinking water
regulations (NPDWR)… The term “NPDWR violations” is used in this subpart to
include violations of the maximum contaminant level (MCL),.... monitoring
requirements, and testing procedures in this part 141.
....
Page 62 of 86
(b) What type of public notice is required for each violation or situation? Public
notice requirements are divided into three tiers, to take into account the
seriousness of the violation or situation and of any potential adverse health effects
that may be involved….
Table 2 to § 141.201—Definition of Public Notice Tiers

(1) Tier 1 public notice—required for NPDWR violations and situations with
significant potential to have serious adverse effects on human health as a result
of short-term exposure.
(2) Tier 2 public notice—required for all other NPDWR violations and situations
with potential to have serious adverse effects on human health.
(3) Tier 3 public notice—required for all other NPDWR violations and situations
not included in Tier 1 and Tier 2.
(c) Who must be notified?

(1) Each public water system must provide public notice to persons served by
the water system, in accordance with this subpart.…
….
(3) A copy of the notice must also be sent to the primacy agency and the
Administrator (as applicable) in accordance with the requirements of §
141.31(d).
40 C.F.R. §141.202- Tier 1 Public Notice- Form, manner, and frequency of notice.
(a) Which violations or situations require a Tier 1 public notice? Table 1 of this
section lists the violation categories and other situations requiring a Tier 1 public
notice. Appendix A to this subpart identifies the tier assignment for each specific
violation or situation.
Table 1 to § 141.202—Violation Categories and Other Situations Requiring a

Tier 1 Public Notice
(1) Violation of the MCL for total coliforms when fecal coliform or E. coli are
present in the water distribution system (as specified in § 141.63(b)), or when
the water system fails to test for fecal coliforms or E. coli when any repeat
sample tests positive for coliform (as specified in § 141.21(e)); Violation of the
MCL for E. coli (as specified in § 141.63(c));
….
(8) Detection of E. coli, enterococci, or coliphage in source water samples as
specified in § 141.402(a) and § 141.402(b);…
….
(b) When is the Tier 1 public notice to be provided? What additional steps are
required? Public water systems must:
(1) Provide a public notice as soon as practical but no later than 24 hours after
the system learns of the violation;
Page 63 of 86
(2) Initiate consultation with the primacy agency as soon as practical, but no later
than 24 hours after the public water system learns of the violation or situation, to
determine additional public notice requirements; and
(3) Comply with any additional public notification requirements (including any
repeat notices or direction on the duration of the posted notices) that are
established as a result of the consultation with the primacy agency....
40 C.F.R. §141.203- Tier 2 Public Notice—Form, manner, and frequency of notice.
(a) Which violations or situations require a Tier 2 public notice? Table 1 of this
section lists the violation categories and other situations requiring a Tier 2 public
notice. Appendix A to this subpart identifies the tier assignment for each specific
violation or situation.
Table 1 to § 141.203—Violation Categories and Other Situations Requiring a

Tier 2 Public Notice
(1) All violations of the MCL, MRDL, and treatment technique requirements,
except where a Tier 1 notice is required under § 141.202(a) or where the primacy
agency determines that a Tier 1 notice is required;
….
(b) When is the Tier 2 public notice to be provided?
(1) Public water systems must provide the public notice as soon as practical, but
no later than 30 days after the system learns of the violation….
(2) The public water system must repeat the notice every three months as long
as the violation or situation persists, unless the primacy agency determines that
appropriate circumstances warrant a different repeat notice frequency….
….
Subpart S—Ground Water Rule
40 C.F.R. §141.400 -General requirements and applicability.

(a) Scope of this subpart. The requirements of this subpart S constitute National
Primary Drinking Water Regulations.
(b) Applicability. This subpart applies to all public water systems that use ground
water except that it does not apply to public water systems that combine all of their
ground water with surface water or with ground water under the direct influence of
surface water prior to treatment under subpart H. For the purposes of this subpart,
“ground water system” is defined as any public water system meeting this
applicability statement, including consecutive systems receiving finished ground
water.
….
Page 64 of 86
40 C.F.R. §141.402- Ground Water Source Microbial Monitoring and Analytical Methods.
(a) Triggered source water monitoring—
(1) General requirements. A ground water system must conduct triggered
source water monitoring if the conditions identified in paragraphs (a)(1)(i)
and either (a)(1)(ii) or (a)(1)(iii) of this section exist.
(i) The system does not provide at least 4–log treatment of viruses (using
inactivation, removal, or a State-approved combination of 4–log virus
inactivation and removal) before or at the first customer for each ground water
source; and either
(ii) The system is notified that a sample collected under § 141.21(a) is total
coliform-positive and the sample is not invalidated under § 141.21(c) until
March 31, 2016, or
(iii) The system is notified that a sample collected under §§ 141.854
through 141.857 is total coliform-positive and the sample is not invalidated
under § 141.853(c) beginning April 1, 2016.
(2) Sampling requirements. A ground water system must collect, within 24
hours of notification of the total coliform-positive sample, at least one
ground water source sample from each ground water source in use at the
time the total coliform-positive sample was ….. collected under §§ 141.854
through 141.857 beginning April 1, 2016, ….
(3) Additional requirements. If the State does not require corrective action
under § 141.403(a)(2) for a fecal indicator-positive source water sample
collected under paragraph (a)(2) of this section that is not invalidated under
paragraph (d) of this section, the system must collect five additional source
water samples from the same source within 24 hours of being notified of
the fecal indicator-positive sample.
….
(g) Public notification. A ground water system with a ground water source
sample collected under paragraph (a) or (b) of this section that is fecal
indicator-positive and that is not invalidated under paragraph (d) of this section,
including consecutive systems served by the ground water source, must conduct
public notification under § 141.202.
(h) Monitoring violations. Failure to meet the requirements of paragraphs (a)-(f) of
this section is a monitoring violation and requires the ground water system to
provide public notification under § 141.204.
[Emphasis added]
….
40 C.F.R. §141.403 Treatment Technique Requirements for Ground Water Systems.

(a) Ground water systems with significant deficiencies or source water fecal
contamination.
Page 65 of 86
(1) The treatment technique requirements of this section must be met by ground
water systems when a significant deficiency is identified or when a ground water
source sample collected under § 141.402(a)(3) is fecal indicator-positive.
(2) If directed by the State, a ground water system with a ground water source
sample collected under § 141.402(a)(2), § 141.402(a)(4), or § 141.402(b) that is
fecal indicator-positive must comply with the treatment technique requirements
of this section.
….
Subpart Y—Revised Total Coliform Rule
40 C.F.R. §141.851 – General.
(a) General. The provisions of this subpart include both maximum contaminant
level and treatment technique requirements.
(b) Applicability. The provisions of this subpart apply to all public water systems.
(c) Compliance date. Systems must comply with the provisions of this subpart
beginning April 1, 2016, unless otherwise specified in this subpart.
….
(e) Violations of national primary drinking water regulations. Failure to comply with
the applicable requirements of §§141.851 through 141.861, including
requirements established by the State pursuant to these provisions, is a violation
of the national primary drinking water regulations under subpart Y.
….
40 C.F.R. § 141.853 - General monitoring requirements for all public water systems.
(a) Sample siting plans.
(1) Systems must develop a written sample siting plan that identifies sampling
sites and a sample collection schedule that are representative of water
throughout the distribution system not later than March 31, 2016. These plans
are subject to State review and revision. Systems must collect total coliform
samples according to the written sample siting plan…
(2) Systems must collect samples at regular time intervals throughout the
month…
….
(5) Systems must identify repeat monitoring locations in the sample siting
plan. Unless the provisions of paragraphs (a)(5)(i) or (a)(5)(ii) of this section
are met, the system must collect at least one repeat sample from the
sampling tap where the original total coliform-positive sample was taken,
and at least one repeat sample at a tap within five service connections
upstream and at least one repeat sample at a tap within five service
connections downstream of the original sampling site. If a total coliform-
positive sample is at the end of the distribution system, or one service connection
Page 66 of 86
away from the end of the distribution system, the system must still take all
required repeat samples….
[Emphasis added]
40 C.F.R. §141.857 Routine monitoring requirements for public water systems

serving more than 1,000 people.
(a) General.
(1) The provisions of this section apply to public water systems serving more than
1,000 persons.
(2) Following any total coliform-positive sample taken under the provisions
of this section, systems must comply with the repeat monitoring
requirements and E. coli analytical requirements in § 141.858.
….
(b) Monitoring frequency for total coliforms. The monitoring frequency for
total coliforms is based on the population served by the system, as follows:
Total Coliform Monitoring Frequency for Public Water Systems Serving More
Than 1,000 People
Population served Minimum number of samples per month
1,001 to 2,500 2
2,501 to 3,300 3
3,301 to 4,100 4
4,101 to 4,900 5
4,901 to 5,800 6
5,801 to 6,700 7
6,701 to 7,600 8
7,601 to 8,500 9
8,501 to 12,900 10
12,901 to 17,200 15
17,201 to 21,500 20
21,501 to 25,000 25
25,001 to 33,000 30
33,001 to 41,000 40
41,001 to 50,000 50
*Remainder of Chart Intentionally Left Blank

[Emphasis added]
….
Page 67 of 86
40 C.F.R. §141.858 Repeat monitoring and E. coli requirements.

(a) Repeat monitoring.
(1) If a sample taken under §§ 141.854 through 141.857 is total coliform-
positive, the system must collect a set of repeat samples within 24 hours
of being notified of the positive result. The system must collect no fewer
than three repeat samples for each total coliform-positive sample found....
(2) The system must collect all repeat samples on the same day, except that
the State may allow a system with a single service connection to collect the
required set of repeat samples over a three-day period or to collect a larger
volume repeat sample(s) in one or more sample containers of any size, as long
as the total volume collected is at least 300 ml.
(3) The system must collect an additional set of repeat samples in the
manner specified in paragraphs (a)(1) through (a)(3) of this section if one
or more repeat samples in the current set of repeat samples is total
coliform-positive. The system must collect the additional set of repeat
samples within 24 hours of being notified of the positive result. The system
must continue to collect additional sets of repeat samples until either total
coliforms are not detected in one complete set of repeat samples ….
(4) After a system collects a routine sample and before it learns the results of the
analysis of that sample, if it collects another routine sample(s) from within five
adjacent service connections of the initial sample, and the initial sample, after
analysis, is found to contain total coliforms, then the system may count the
subsequent sample(s) as a repeat sample instead of as a routine sample….
(b) Escherichia coli (E. coli) testing.

(1) If any routine or repeat sample is total coliform-positive, the system
must analyze that total coliform-positive culture medium to determine if E.
coli are present. If E. coli are present, the system must notify the State by
the end of the day when the system is notified of the test result, unless the
system is notified of the result after the State office is closed and the State does
not have either an after-hours phone line or an alternative notification procedure,
in which case the system must notify the State before the end of the next
business day.
[Emphasis added]
§ 141.859 Coliform treatment technique triggers and assessment requirements for

protection against potential fecal contamination.
(a) Treatment technique triggers. Systems must conduct assessments in

accordance with paragraph (b) of this section after exceeding treatment technique
triggers in paragraphs (a)(1) and (a)(2) of this section.
Page 68 of 86
Florida Safe Drinking Water Act and Implementing Regulations
Part VI. Water Supply; Water Treatment Plants (403.850 to 403.892)
Section 403.850., F.S.- Short title.

This act may be cited as the “Florida Safe Drinking Water Act.”
….
Section 403.853, F.S. – Drinking Water Standards.
(1) The department shall adopt and enforce:

(a)1. State primary drinking water regulations that shall be no less stringent at
any given time than the complete interim or revised national primary drinking
water regulations in effect at such time; and
2. State secondary drinking water regulations patterned after the national
secondary drinking water regulations….
….
Section 403.857, F.S.- Notification of users and regulatory agencies.
Whenever a public water supply system:

(1) Is not in compliance with the state primary and secondary drinking water
regulations;
(2) Fails to perform monitoring required by rules or regulations adopted by the
department;
….
the owner or operator of the system shall, as soon as practicable, notify the local
public health departments, the department, and the communications media
serving the area served by the system of that fact and of the extent, nature, and
possible health effects of such fact. Such notice shall also be given by the owner
or operator of the system by publication in a newspaper of general circulation, as
determined by the department, within the area served by such water system at
least once every 3 months as long as the violation….. continues. Such notice shall
also be given with the water bills of the system as long as the violation, variance,
or exemption continues, as follows: if the water bills of a public water system are
issued at least as often as once every 3 months, such notice shall be included in
at least one water bill of the system for each customer every 3 months; if the
system issues its water bills less often than once every 3 months, such notice shall
be included in each of the water bills issued by the system for each customer.
However, the provisions of this section notwithstanding, the department may
prescribe by rule reasonable alternative notice requirements.
Page 69 of 86
Chapter 62-550, F.A.C.- Drinking Water Standards, Monitoring, and Reporting
Rule 62-550.102, F.A.C.- Intent and Scope.

(1) To assure that public water systems supply drinking water which meets
minimum requirements, the Federal Government enacted PL 93-523, the “Safe
Drinking Water Act.” The scheme of that law was to give primary responsibility for
public water systems programs to states to implement a public water system
program. Also, the legislature of Florida has enacted the “Florida Safe Drinking
Water Act,” Sections 403.850-.864, F.S. This chapter [62-550] and Chapters 62-
555 and 62-560, F.A.C., are promulgated to implement the requirements of the
Florida Safe Drinking Water Act and to acquire and maintain primacy for Florida
under the Federal Act. This chapter [62-550] and Chapters 62-555 and 62-560,
F.A.C., adopt national primary and secondary drinking water standards of the
Federal Government where possible, and otherwise create additional rules to fulfill
state and Federal requirements.
….
Rule 62-550.310, F.A.C.- Primary Drinking Water Standards: Maximum Contaminant
Levels and Maximum Residual Disinfectant Levels.
….
(5) Microbiological - This subsection applies to all public water systems.
….Beginning April 1, 2016, monitoring requirements to demonstrate compliance
with this subsection are defined in Rule 62-550.830, F.A.C.
….
(d) Beginning April 1, 2016, a system is in compliance with the MCL for E. coli for
samples taken under the provisions of 40 C.F.R. Part 141, Subpart Y, which is
incorporated by reference in Rule 62.550.830, F.A.C., unless any of the conditions
identified in the following subparagraphs 1. through 4. occur….
1. The system has an E. coli-positive repeat sample following a total coliform-
positive routine sample…..
2. The system has a total coliform-positive repeat sample following an E. coli-
positive routine sample….
3. The system fails to take all required repeat samples following an E. coli-
positive routine sample….
4. The system fails to test for E. coli when any repeat sample tests positive for
total coliform….
(e) Beginning April 1, 2016, a public water system must determine compliance with
the MCL for E. coli in paragraph 62-550.310(5)(d), F.A.C., for each month in which
it is required to monitor for total coliforms….
Rule 62-550.730, F.A.C.- Reporting Requirements for Public Water Systems.
Suppliers of water and DOH-certified laboratories shall report as follows:

(1) Suppliers of Water.
Page 70 of 86
(a) Except where a shorter reporting period is specified in this chapter, the
suppliers of water shall report to the appropriate District office of the
Department or Approved County Health Department the results of the test
measurement or analysis required by this chapter within the first ten days
following the end of the required monitoring period as designated by the
Department, or the first ten days following the month in which the sample
results were received, whichever time is shortest.
(b) The supplier of water shall use the format described in subparagraphs 1.
through 9. below for reporting all water analysis results for inorganics,…..
….
(e) The supplier of water shall report to the appropriate Department of
Environmental Protection District Office or appropriate Approved County
Health Department within 48 hours (unless otherwise specified by the chapter)
the failure to comply with any drinking water rule contained in Parts III, V, or
VIII of this chapter, or Part IV of Chapter 62-560, F.A.C. When compliance is
achieved, the measures taken shall be reported to that office.
[Emphasis added]
Rule 62-550.828, F.A.C. – Ground Water Rule.
(1) The requirements contained in the July 1, 2014, edition of 40 C.F.R. Part 141,
Subpart S (Sections 141.400 through 141.405)…. are adopted and incorporated
herein by reference and are enforceable under this rule, except the following
regulations are not adopted or incorporated in this rule…
(2) In addition to the public notification requirements in Part IV of Chapter 62-560,
F.A.C., the following public notification requirements are adopted and incorporated
herein by reference and are enforceable under this rule:
(a) ….the Tier 1 public notice requirements pertaining to detection of E. coli,
enterococci, or coliphage in source water samples required under 40 C.F.R. §§
141.402(a) and 141.402(b)…, which are incorporated by reference in subsection
62-550.828(1), F.A.C.
Rule 62-550-830, F.A.C. – Revised Total Coliform Rule.

(1) The requirements contained in 40 C.F.R. Part 141, Subpart Y (Sections
141.851 through 141.861),… are adopted and incorporated herein by reference
and are enforceable under this rule, ….
(2) In addition to the public notification requirements in Rules 62-560.400, 62-
560.410, 62-560.430, and 62-560.440, F.A.C., the following public notification
requirements are adopted and incorporated herein by reference and are
enforceable under this rule:
(a) The Tier 1 public notice requirements in 40 C.F.R. § 141.202 …. pertaining
to a violation of the MCL for E. coli as specified in paragraph 62-550.310(5)(d),
F.A.C. A system is in compliance with the MCL for E. coli for samples taken
under the provisions of 40 C.F.R. Part 141, Subpart Y, which is incorporated by
Page 71 of 86
reference in Rule 62-550.830, F.A.C., unless any of the conditions specified in

paragraph 62-550.310(5)(d), F.A.C., occur….
Chapter 62-555, F.A.C.- Permitting, Construction, Operation, and Maintenance of

Public Water Systems
Rule 62-555.310, F.A.C.- Source and Sitting Requirements for Public Water Systems.
(1) Suppliers of water shall obtain raw water from the best available source that is
economically sensible and technically possible and shall make an effort to protect
the source from contamination.
Rule 62-555.315- Public Water System Wells—Security; Number; Capacity; Under the
Direct Influence of Surface Water; Control of Copper Pipe Corrosion and Black Water;
and Disinfection and Bacteriological Surveys and Evaluations.
….
(6) Disinfection of Wells and Bacteriological Surveys and Evaluations of Wells.

Wells shall be disinfected to inactivate any microbiological contaminant that may
have been introduced into the wells during construction, repair, or maintenance
and to allow the true microbiological character of well water to be determined
through a bacteriological survey.
(a) Before new or altered wells, wells out of operation for more than six
months, wells in which new pumping equipment has been installed, and wells
taken out of operation for maintenance that might have contaminated the well
are placed into, or returned to, operation, they shall be disinfected in accordance
with Sections 1. through 4….
(b) Following disinfection of a new or altered well or a well that has been out of
operation for more than six months, a bacteriological survey of the well shall
be conducted ….
1. A total of at least 20 samples -- each taken on a separate but consecutive

workday and taken at least six hours apart from the other samples -- shall be
collected after first pumping the well to waste to remove all residual chlorine and
then pumping the well to waste at a rate approximately equal to that of the
permanent well pump for at least 15 minutes before each sample is collected,
and the samples shall be analyzed for the presence of total residual chlorine,
total coliform, and E. coli…If the Department allows collection of two samples per
day, the samples shall be collected at least six hours apart, and the well shall be
pumped to waste for at least 15 minutes before each sample is collected.
2. …. If any sample shows the presence of E. coli, the well shall be

considered microbially contaminated unless the Department invalidates the
sample or the supplier of water determines and eliminates the source of the E.
Page 72 of 86
coli, in which case the well shall be redisinfected in accordance with paragraph
(a), above, and resampled in accordance with subparagraph 1. above. If more
than ten percent of the total number of samples collected show the presence of
total coliform or if either of the last two samples collected shows the
presence of total coliform, the well shall be redisinfected as necessary in
accordance with paragraph (a), above, and resampled in accordance with
subparagraph 1. above or shall be considered susceptible to microbial
contamination. If a well is considered microbially contaminated or susceptible
to microbial contamination, the supplier of water shall provide treatment that
reliably achieves at least four-log inactivation or removal of viruses in accordance
with paragraph 62-555.320(12)(b), F.A.C. Additionally, the supplier of water shall
conduct physical characteristics monitoring in accordance with subsection 62-
550.517(2), F.A.C., when notified in writing by the Department to do so.
….
(f) All public water systems using ground water not under the direct influence of
surface water are required by subsections 62-550.518(2), (3), and (10), F.A.C.,
to periodically sample the raw ground water for microbiological contamination. In
the event a raw water sample is positive for E. coli, the relevant well(s) shall be
considered microbially contaminated unless the Department invalidates the
sample or the supplier of water determines and eliminates the source of the E.
coli, after which the supplier of water shall disinfect and bacteriologically survey
the well(s) in accordance with paragraphs (a) and (b), above. If a raw water
sample is positive for total coliform bacteria and if the relevant well(s) are not
already considered microbially contaminated or susceptible to microbial
contamination, the supplier of water shall disinfect and bacteriologically survey
the well(s) in accordance with paragraphs (a) and (b), above when notified in
writing by the Department to do so.
[Emphasis added]
Chapter 62-560, F.A.C. – Requirements for Public Water Systems that Are Out of
Compliance
Rule 62-560.310, F.A.C. Violations.
(1) Prohibited Acts.
(a) Failure by a supplier of water to comply with the requirements of Section

403.857, F.S., or dissemination by such supplier of any false or misleading
information with respect to notices required pursuant to Section 403.857, F.S.,
or with respect to remedial actions being undertaken to achieve compliance
with state primary and secondary drinking water standards.
(b) Failure by a supplier of water to comply with rules adopted pursuant to
Section 403.853, F.S., or any rule adopted by the Department pursuant to the
Florida Safe Drinking Water Act,
Page 73 of 86
….
(e) Submission by any person of any false statement or representation in any

application, record, report, plan or other document filed, or required to be filed
by the Florida Safe Drinking Water Act, or rules adopted by the Department
pursuant to its lawful authority.
(2) Penalties.
(a) The Department shall assess administrative penalties for violations of
subsection (1), above, in accordance with Section 403.121, F.S.
…..
Rule 62-560.400, F.A.C. - Scope of Drinking Water Public Notification Rules.
The following sections set forth the requirements that a supplier of water shall meet
when public notification is required. In addition to the requirements described in this
part, the following requirements and appendices are adopted and incorporated herein
by reference:
….
(2) .... the Tier 1 public notice requirements pertaining to detection of E. coli,
enterococci, or coliphage in source water samples required under 40 C.F.R. §§
141.402(a) and 141.402(b) (July 1, 2014), which are incorporated by reference
in subsection 62-550.828(1), F.A.C.
(3)… the Tier 2 public notice requirements pertaining to failure to take corrective
action…which is incorporated by reference in subsection 62-550.828(1), F.A.C.
Rule 62-560.410. Public Notification- Primary Standards.
(1) Maximum Contaminant Level, Maximum Residual Disinfectant Level, Treatment

Technique Requirement, Variance or Exemption Schedule Violations, and
Exceedances. The owner or operator of a public water system that fails to comply
with an applicable maximum contaminant level, maximum residual disinfectant level,
or treatment technique requirement established by Chapter 62-550, F.A.C., or that
fails to comply with the requirements of any schedule prescribed pursuant to a
variance or exemption shall notify persons served by the system….
(a) Except as provided in paragraph (1)(c) or (1)(d) of this rule, the owner or
operator of a public water system shall give notice:
1. For violations, exceedances, situations, or failures, that may pose an acute risk
to human health, by furnishing a copy of the Tier 1 notice to the radio and television
stations that broadcast in the area served by the public water system as soon as
possible but in no case later than 24 hours after the system learns of the violation,
exceedance, situation, or failure, unless otherwise directed by the Department to
provide such public notice sooner because of the nature of the risk. The system
shall also initiate consultation with the Department as soon as possible, but in no
case later than 24 hours after the system learns of the violation, exceedance,
Page 74 of 86
situation, or failure, as described in subparagraphs a. through g., below, to

determine additional public notice requirements that may be necessary to protect
public health….
….
b. Violation of the maximum contaminant level for fecal coliform or E. coli in
the water distribution system, as specified in paragraph 62-550.310(5)(b), or
failure to test for fecal coliforms or E. coli when any repeat sample tests
positive for coliforms as specified in subsection 62-550.518(10), F.A.C.
Page 75 of 86
APPENDIX 2
Page 76 of 86
Page 77 of 86
Page 78 of 86
APPENDIX 3
Page 79 of 86
Page 80 of 86
ATTACHMENT A
Response from City of Riviera Beach
CITY OF RIVIERA BEACH – UTILITY SPECIAL DISTRICT
TO: JOHN A. CAREY, INSPECTOR GENERAL – PALM BACH COUNTY OIG
FROM: JONATHAN EVANS, CITY MANAGER, MPA, MBA, FRA-RA, ICMA-CM
SUBJECT: INVESTIGATIVE REPORT 2024 – 0006 – RBUSD RESPONSE
DATE: NOV. 14, 2024
This memorandum presents a comprehensive overview of the corrective measures and operational
improvements implemented by the Riviera Beach Utility Special District (RBUSD) in response to
compliance and water quality challenges identified in 2023. Prompted by a recent Florida Department of
Health (FDOH) Warning Letter and findings from the Office of Inspector General (OIG), RBUSD
leadership has taken responsibility for these past issues and committed to an extensive overhaul of practices,
standards, and procedures to ensure public health and safety. It is noteworthy that all individuals implicated
in the 2023 issues are no longer employed with RBUSD, further underscoring the district’s commitment to
accountability and reform.
Clarification of Reporting Compliance Instances
Following a detailed review of the 2023 compliance findings, which originally identified 151 alleged
instances of failure to meet reporting requirements, the Riviera Beach Utility Special District (RBUSD)
Compliance Manager confirmed that 23 of these instances were, in fact, compliant. Through examination
of records and supporting documentation, it was determined that laboratory reports for these 23 occurrences
were submitted to the Florida Department of Health (FDOH) in accordance with all regulatory
requirements.
To ensure transparency and accuracy, RBUSD provided this documentation to the FDOH on October 23,
2024, for their review and consideration prior to any final enforcement action. This clarification
demonstrates RBUSD’s commitment to maintaining rigorous compliance standards and collaborating
closely with FDOH to address and resolve regulatory matters accurately.
Comprehensive Actions Undertaken by RBUSD
In an effort to enhance RBUSD’s compliance standards and reinforce staff expertise in water quality
management, an assessment of the City’s Compliance Department is currently underway. This assessment,
led by our consultants, includes a thorough review of water quality data, regulatory reports such as Monthly
Operating Reports (MORs), applicable Plans and Standard Operating Procedures (SOPs), field sampling
procedures, laboratory analyses, and recordkeeping practices associated with sampling and laboratory
activities.
Delineated below, are the certain activities that have been more recently developed and established to
effectuate successful outcomes:
• Revamped Bacteriological Sampling and Compliance Plan:

o Action Details: RBUSD developed an extensive Bacteriological Sampling Plan, thoroughly
reviewed and approved by both the USEPA and FDOH. The plan stipulates clear guidelines
on sampling sites, collection schedules, and protocols for documenting and reporting results.
o Objective: This Plan addresses previous deficiencies by setting stringent procedures to
prevent reporting delays, improve test accuracy, and mandate compliance with the Safe
Drinking Water Act at all levels.
o Training and Implementation: Staff will receive dedicated training on adhering to this plan,
with performance evaluations tied to compliance metrics to enforce accountability.
Additionally, this Plan is now central to RBUSD's ongoing quality assurance audits.
• Strategic Collaboration with US Water Corporation:

o Purpose and Scope: To remediate systemic issues in operations, RBUSD engaged US Water
Corporation, a leader in utility management services, to provide both operational support
and expertise.
o Process Improvements: US Water Corporation is facilitating process enhancements,
including optimization of lime softening procedures, addressing deferred maintenance, and
improving distribution system reliability.
o Training and Oversight: This partnership includes a comprehensive staff training program,
covering water quality protocols, safety measures, and compliance reporting. US Water
Corporation's involvement ensures that these training sessions meet national standards and
equip staff with industry-leading practices in water utility management.
• Implementation of iWater GIS-Based Asset and Compliance Management System:

o System Overview: RBUSD has introduced the iWater system, an advanced Geographic
Information System (GIS) platform that consolidates work orders, maintenance records,
customer complaints, and water quality data.
o Benefits and Impact: By integrating these operational aspects into a unified system, RBUSD
will be able to track compliance trends, respond quickly to maintenance issues, and analyze
water quality data in real-time. This technology facilitates transparent reporting to both
regulatory bodies and the public.
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o Operational Impact: The system's detailed tracking and reporting capabilities also provide
an audit trail for compliance verification, improving operational oversight and enabling
proactive maintenance scheduling.
• GlobalTech Wellfield Rehabilitation and Inspection Program:
As part of RBUSD's commitment to enhancing the integrity and reliability of its water supply, the
Riviera Beach Utility Special District (RBUSD) has engaged GlobalTech to lead a comprehensive
rehabilitation and inspection program across its wellfields. This initiative is designed to ensure that
all wells meet stringent regulatory standards, operational efficiency metrics, and safety
requirements, aligning with RBUSD's dedication to maintaining a high standard of water quality for
its residents.
o Inspection and Maintenance: GlobalTech has been contracted to conduct extensive inspections
of the RBUSD wellfield, focusing on each well's structural integrity, operational performance,
and compliance with regulatory guidelines. These inspections are essential for identifying any
maintenance needs, ensuring all wells operate within the parameters required for safe and
sustainable water distribution.
o Rehabilitation Measures: In addition to routine inspections, GlobalTech is actively

implementing a series of rehabilitative actions across the wellfield to address wells that require
urgent repair. Specific measures include well cleanings, seal repairs, and mechanical upgrades
to restore full functionality and enhance the safety and reliability of the groundwater supply. As
of this update:
- Well 14 has undergone rehabilitation and is currently back in service.

- Well 12A has also been rehabilitated and is awaiting final approval from the Florida
Department of Health (FDOH) to be placed back in service.
- Well 921 has been permitted and rehabilitated. Certification of completion, along
with a request for clearance, is expected to be submitted to the City and FDOH
imminently to expedite its return to service.
In addition to these specific wells, GlobalTech has initiated rehabilitation on several other wells within the
RBUSD system as part of a targeted effort to bring all wells up to optimal standards.
o Expanded Scope of Rehabilitation: To address both immediate and long-term needs,

GlobalTech's scope includes the substantial rehabilitation of a total of twelve (12) wells. This
includes emergency rehabilitation for seven (7) wells that had previously been out of service
and substantial upgrades for an additional five (5) wells. The total investment for this critical
initiative is valued at $4,883,045.74, reflecting RBUSD's commitment to infrastructure
resiliency and water quality.
• Enhanced Communication and Accountability Framework:

o Communication Plan: RBUSD established a formalized Communication Plan to prevent the
lapses in reporting and transparency previously encountered. This plan includes redundant
3
communication lines between RBUSD, testing laboratories, and regulatory agencies to
ensure prompt, accurate information dissemination.
o Defined Roles and Responsibilities: The Communication Plan specifies clear roles for each
team member, including who is responsible for initiating communications and managing
follow-ups on critical compliance matters. Each role is backed by documented
accountability standards.
o Internal Auditing: This plan includes periodic audits to verify that all communication
procedures are being followed correctly, with a dedicated oversight team assigned to address
any deviations promptly.
• Focused Staff Training and Professional Development Program:
Based on the findings of this assessment, our consultants are developing a continuing education
training program scheduled for early December. This training will span approximately three days
and will be conducted twice to accommodate all relevant personnel. The training sessions, which
will include both classroom theory and practice instruction and hands-on practice, will cover key
aspects of drinking water regulations at both the federal and state levels, proper procedures for
Water Treatment Plant (WTP) and field sampling, adherence to approved laboratory analysis
methods, and the required standards for documentation and recordkeeping. This initiative
underscores RBUSD’s commitment to compliance and continuous improvement in water quality
and regulatory practices.
o Objective: Recognizing the importance of a skilled and competent workforce, RBUSD, in

collaboration with US Water Corporation, will enhance its training protocols to address
every critical facet of water treatment, quality assurance, and regulatory compliance. This
program aims to elevate the proficiency and accountability of all Utility Special District
(USD) employees.
o Training Components: The enhanced training program includes both initial and ongoing
sessions covering essential topics such as water testing, emergency response, and precise
documentation practices. As part of this initiative, compliance training is now a mandatory
element of the onboarding process for all new hires. Additionally, in-service training
sessions, supplemented by video modules, will be required throughout the year. Testing will
ensure that each employee fully understands the regulatory standards and operational
procedures essential for their role.
o Evaluation and Certification: To reinforce a high standard of regulatory adherence, RBUSD
requires the Water Plant Manager to certify that all operators complete their annual
Continuing Education Units (CEUs). Each employee's progress and performance in the
training program are monitored closely, with evaluations incorporated into annual reviews.
Remedial training will be provided for any employees who encounter difficulties meeting
the compliance benchmarks, ensuring they achieve the necessary competency. These
evaluation and certification measures strengthen RBUSD’s commitment to public trust and
regulatory integrity.
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• Advancement of the New Water Treatment Facility:
o Project Overview: RBUSD has continued its work on the development of a new Water
Treatment Plant, projected to employ nanofiltration and reverse osmosis technologies—
considered some of the most effective treatment methods available for ensuring the safety
of drinking water.
o Design and Construction Status: The plant’s design is currently 60% complete, with
additional efforts to address water quality challenges and operational efficiency. The facility
aims to set a high standard for water safety and reliability within Riviera Beach.
o Enhanced Water Quality Assurance: This facility will also be equipped with modernized
monitoring systems for real-time water quality analysis, which will further assure customers
of the safety and quality of their drinking water.
Commitment to Transparency and Accountability
On November 13, 2024, RBUSD leadership held a presentation detailing the Mission Statement,
Objectives, and Core Values, delivered by the City Manager and Assistant City Manager. During this
session, USD employees were briefed on our new guiding principles, which include:
- Mission Objectives: Focusing on public health and safety, operational efficiency, environmental
stewardship, community transparency, staff development, and emergency preparedness.
- Core Values (I-REACT): Integrity, Responsibility, Excellence, Adaptability, Collaboration, and
Trust, which collectively reinforce our commitment to the public and regulatory compliance.
Each employee has signed an acknowledgment form committing to uphold these principles and embody
the RBUSD’s commitment to integrity, service excellence, and public trust. This acknowledgment is
maintained as a part of their official records, holding them accountable to the standards and values of the
Utility Special District.
In summary, RBUSD is dedicated to corrective action and full compliance, ensuring the safety and quality
of water services for Riviera Beach customers. We are committed to continued cooperation with the OIG,
FDOH, FDEP and any other regulatory agencies to uphold our responsibilities to public health and
environmental safety.
Should additional details be required on the actions established, please reach out to our office directly.
Attachment(s):
o Utility Special District 2024: Mission, Objective, and Core Values PowerPoint
o Compliance, Accountability, and Operational Excellence Memorandum
o USD Mission Statement, Objectives and Core Values
5
Utility Special District 2024: Mission,
Objectives, and Core Values.
November 13, 2024
Presenter(s): City Manager, Jonathan Evans, MPA, MBA, FRA- RA, ICMA – CM.
Assistant City Manager, Deirdre Jacobs, MPA
NEW MISSION STATEMENT
“Our mission is to deliver safe, reliable, and sustainable water
and wastewater services that enhance public health, protect
the environment, and support Riviera Beach customers’ quality
of life. Through innovation, integrity, and a steadfast
commitment to excellence, we work to earn and maintain the
trust of the customers we serve.”
Est. Nov. 2024
NEW MISSION OBJECTIVES
• Ensure Public Health and Safety: Uphold stringent water and wastewater quality
standards, ensuring compliance with all regulations to protect public health.
• Enhance Efficiency: Implement best practices in water and wastewater
management to optimize resources and improve reliability.
• Promote Environmental Stewardship: Adopt environmentally responsible
practices across all operations.
• Foster Community Trust and Transparency: Strengthen public trust through
proactive communication and transparent reporting.
• Invest in Staff Development and Training: Develop a knowledgeable workforce
through education and skill-building opportunities.
• Prepare for Emergencies and Adapt to Change: Maintain contingency plans for
service continuity in emergencies, adapting to evolving standards.
USD COMPLIANCE, ACCOUNTABILITY, AND OPERATIONAL EXCELLENCE
This memorandum serves as a directive to all Utility Special
District (USD) staff on the standards, responsibilities, and
expectations that govern our essential work. Our team’s work
directly impacts Riviera Beach residents’ health, safety, and
well-being. We are all responsible for maintaining the highest
standards of professionalism, compliance, and transparency.
ADHERENCE TO CHAIN OF COMMAND
Each team member must follow the established chain of
command, which includes Supervisors, Managers, Directors,
and Administration. This structure is essential for
accountability, clear communication, and coordinated decision-
making. Report all concerns and incidents promptly to ensure
effective resolution.
COMMITMENT TO COMPLIANCE AND
TRANSPARENCY
Compliance with all regulations is mandatory, covering
the Florida Safe Drinking Water Act, Federal Safe
Drinking Water Act, and specific chapters of the Florida
Administrative Code. Prompt, factual communication is
crucial, particularly in reporting incidents and issues in
water and sewer operations. All documentation must be
accurate, timely, and transparent to maintain public trust.
PROFESSIONALISM AND ACCOUNTABILITY
Each staff member must maintain professionalism in
appearance and conduct. Respect, cooperation, and teamwork
are essential. Unacceptable behaviors such as gossiping or
loitering during work hours are not tolerated, and security
protocols must be followed rigorously. Only authorized
personnel are allowed on USD grounds, ensuring a
professional and secure environment.
TRAINING, INTEGRITY, AND CONTINUOUS
IMPROVEMENT
Ongoing training and certifications are required to stay current
with all standards. Integrity and honesty are the foundation of
USD operations, ensuring truthfulness in every report and
interaction. Commitment to these values supports compliance,
public trust, and professional growth.
CORE VALUES – I-REACT
• Integrity: Uphold the highest ethical standards, ensuring honesty, transparency,
and accountability.
• Responsibility: Embrace our duty to safeguard public health, safety, and the
environment.
• Excellence: Commit to achieving the highest quality standards and continuous
improvement.
• Adaptability: Embrace innovation and forward thinking to meet current and
future demands.
• Collaboration: Foster teamwork and value each team member’s contributions.
• Trust: Build trust through respect, dedication, and professionalism in all service
areas.
COMMITMENT TO OUR MISSION AND VALUES
Each member of USD pledges to uphold the Mission,
Objectives, and Core Values of the Utility Special District. By
embodying the I-REACT principles, we are committed to
maintaining integrity, prioritizing public trust, and delivering
reliable services for the community.
ACKNOWLEDGMENT OF COMMITMENT
By signing below, I acknowledge that I have read, understood, and agree to comply
with the Mission, Objectives, and Core Values outlined. I pledge to uphold these
standards, perform duties with integrity, and prioritize Riviera Beach customers’
health, safety, and trust.
• Signature: __________________________
• Printed Name: __________________________
• Position: __________________________
• Date: __________________________
THANK YOU
TO: ALL USD PERSONNEL (Part Time and Full Time)
SUBJECT: COMPLIANCE, ACCOUNTABILITY, AND OPERATIONAL EXCELLENCE
DATE: NOVEMBER 13, 2024
This memorandum serves as a directive to all Utility Special District (USD) staff on the standards,
responsibilities, and expectations that govern our essential work. Our team’s work directly impacts the
health, safety, and well-being of Riviera Beach residents, and we all share the duty to maintain the highest
standards of professionalism, compliance, and transparency. Our roles and actions are governed by local,
state, and federal regulations, and I expect each member of the USD team to approach their responsibilities
with a sense of urgency, purpose, and accountability.
Adherence to Chain of Command

• Each team member must follow the established chain of command, which includes Supervisors,
Managers, Directors, and Administration. This structure is essential for accountability, clear
communication, and coordinated decision-making. Any concerns, incidents, or operational needs
should be reported promptly and appropriately up the chain, ensuring transparency and effective
resolution. This alignment is critical for our department’s efficiency and integrity.
Commitment to Compliance and Accuracy

• Compliance with all local, state and federal regulations is non-negotiable. Our operations are bound
by the Florida Safe Drinking Water Act, the Federal Safe Drinking Water Act, and relevant
provisions under Chapter 62-550, 62-555, 62-560, 62-602 and 62-699 of the Florida Administrative
Code, as well as specific sewer and wastewater standards under Chapter 62-604 of the Florida
Administrative Code. These guidelines cover essential requirements for water and sewer quality,
testing, reporting, and spill response protocols. Accurate and timely compliance with these
regulations protects public health and demonstrates our commitment to our community.
Transparency and Prompt Communication
• Factual and immediate communication is essential. This applies to all water and sewer operations,
including the accurate and prompt reporting of water testing results, sewer conditions, and any
incidents of sewer spills. All issues, particularly those affecting water and sewer quality or public
safety, must be escalated expeditiously. Ensuring compliance with the reporting requirements under
Chapter 62-604, F.A.C., requires immediate notifications to supervisors and regulatory authorities
when sewer overflows or spills occur. Each of you is expected to prioritize transparency, allowing
for timely action and preventing further risks to public health.
Accountability in Documentation and Reporting

• Precise documentation and truthful reporting are essential. All data, logs, and incident reports must
be factual, thorough, and timely completed in accordance with established guidelines. This is
particularly vital for reporting any non-compliant matters, for which accurate documentation and
immediate communication with supervisors and relevant regulatory bodies are mandated. Any
attempts to falsify, omit, or alter documentation will be addressed with strict disciplinary measures.
Personal and Professional Appearance

• Professionalism is reflected not only in conduct but also in personal appearance. Each staff member
is expected to present themselves appropriately and professionally, underscoring the seriousness
with which we approach our duties. Our appearance and behavior should reflect the trust and
responsibility placed in us by the public.
Teamwork, Conduct, and Professionalism

• A culture of respect, cooperation, and teamwork is essential for our success. Gossiping, sleeping,
loitering, or engaging in non-work-related activities during work hours will not be tolerated, as these
behaviors undermine our collective efforts and professionalism. Each team member is expected to
approach their role with focus, integrity, and a commitment to collaboration. Leaving work early or
abandoning your post without authorization will be treated as job abandonment and addressed
accordingly.
Only licensed, credentialed and authorized staff are permitted on USD grounds. Unauthorized
visitors—including friends, family members, or staff from other departments—are strictly
prohibited from accessing the facility. The safety and security of the plant are critical, and it is
everyone’s responsibility to ensure that only authorized personnel are present at all times. A
professional and secure environment is paramount to our operational success, and I expect each of
you to contribute positively to fostering this atmosphere.
Sense of Urgency and Purpose

• The work we perform is critical to the safety and daily lives of Riviera Beach customers. In water
and sewer operations, a lack of diligence and urgency can have severe consequences for public
health. Any non-compliant matters require immediate attention and conformance. It is imperative
that each of you understands the gravity of your work and approaches it with the responsibility and
purpose it deserves.
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Proactive Problem Resolution and Preparedness
• Anticipating and addressing issues before they escalate are vital to our operations. Every team
member must be proactive, identifying and resolving potential risks in water quality, sewer safety,
and public communication. The same urgency applies to any irregularities in our system,
particularly those impacting health and safety. Compliance with all local, state and federal
guidelines requires that issues are not only managed but that root causes are identified and mitigated.
Continual Training and Improvement

• Ongoing training is critical for compliance and professional growth. Every USD team member must
meet training and certification requirements, keeping current with all water and sewer operation
standards, including Safe Drinking Water Act requirements and sewer management protocols. Our
department will continue to provide training, and it is each employee’s responsibility to take full
advantage of these resources to remain knowledgeable and effective.
Honesty and Integrity

• Above all, honesty and integrity are the foundation of our department. Every action, report, and
interaction must reflect truthfulness and a commitment to ethical standards. I expect each of you to
uphold these values and maintain the public’s trust through honest conduct and transparent
operations.
We serve the City of Riviera Beach in a critical capacity, and the public relies on our diligence and
professionalism. I urge each of you to commit to these expectations fully, recognizing that our work has
direct impacts on public health and safety. Together, we will build a USD team grounded in excellence,
accountability, and respect.
Thank you for your continued dedication to our mission.
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TO: ALL USD PERSONNEL (Part Time and Full Time)
SUBJECT: USD MISSION STATEMENT, OBJECTIVES AND CORE VALUES
DATE: NOVEMBER 13, 2024
As we enter a new chapter of excellence in 2024, I am proud to share our newly adopted Mission Statement,
Objectives, and Core Values for the Utility Special District (USD). These foundational principles serve as the
compass for our work, guiding us in delivering the highest standards of service, accountability, and safety for
our Riviera Beach customers. Our department’s success depends on each team member embracing these values
and objectives, as we reflect on our shared commitment to the public’s trust.
Mission Statement
Our mission is to deliver safe, reliable, and sustainable water and wastewater services that enhance public health,
protect the environment, and support the quality of life for the Riviera Beach customers. Through innovation,
integrity, and a steadfast commitment to excellence, we work to earn and maintain the trust of the customers we
serve.
Objectives
Ensure Public Health and Safety

• Uphold stringent water and wastewater quality standards, ensuring full compliance with local, state, and
federal regulations to protect public health and deliver safe, reliable services.
Enhance Efficiency
• Implement best practices in water and wastewater management to optimize resource use, reduce
operational costs, and improve service reliability for the benefit of our customers.
Promote Environmental Stewardship
• Protect and sustain natural resources by adopting environmentally responsible practices in all operations,
from water treatment to wastewater management.
Foster Community Trust and Transparency

• Build and strengthen public trust through proactive communication, transparent reporting, and timely
responses to customer needs and concerns.
Invest in Staff Development and Training

• Develop a knowledgeable, well-trained, and motivated workforce through ongoing education,
certifications, and skill-building opportunities that support operational excellence.
Prepare for Emergencies and Adapt to Change

• Maintain robust contingency plans to respond swiftly and effectively to emergencies, ensuring
continuity of services under any circumstances and adapting to evolving industry standards.
Core Values – I-REACT
To reinforce our dedication to these objectives and to our customers, we have adopted I-REACT as the acronym
for our core values. I-REACT embodies the standards and principles that are fundamental to our success.
I – Integrity
• Uphold the highest ethical standards, ensuring honesty, transparency, and accountability in every action
and decision. Integrity is the foundation of public trust, and we must exemplify it daily in all we do.
R – Responsibility
• Embrace our duty to safeguard public health, safety, and the environment. We take full responsibility
for the quality, safety, and sustainability of our operations, acknowledging the impact of our work within
the service area.
E – Excellence
• Commit to achieving the highest quality standards and continuous improvement. Striving for excellence
in every task reflects our commitment to providing exceptional services to our customers.
A – Adaptability
• Embrace innovation and forward-thinking as we navigate challenges and evolving industry standards.
Adaptability ensures that we are prepared to meet both current and future demands.
C – Collaboration
• Foster teamwork as the foundation of our success. Each team member’s contributions are valued, and
we rely on each other’s expertise and support to achieve our shared goals.
T – Trust
• Our work is meaningful because the community depends on us. By serving with respect, dedication, and
professionalism, we build and maintain the trust of the people we serve.
2
Signature Acknowledgement
By signing below, I acknowledge that I have read, understood and agreed to comply with the expectations
and standards outlined in this memorandum.
By signing below, I also pledge to uphold the Mission, Objectives, and Core Values of the Utility Special
District. I commit to embody I-REACT in all my actions and decisions, to perform my duties with integrity,
and to prioritize the health, safety, and trust of the Riviera Beach customers. I understand the importance
of my role in delivering reliable, safe, and transparent services, and I will strive to meet and exceed the
standards set forth in this memorandum.
Signature: ______________________________________
Printed Name: ___________________________________
Position: ________________________________________
Date: ___________________________________________
Our Mission, Objectives, and Core Values guide us in our essential work of supporting the Riviera Beach
customers. I encourage each of you to let these principles be the foundation of your daily actions, decisions,
and interactions. Together, through our adherence to I-REACT and our shared commitment to excellence,
we will continue to uphold the highest standards in 2024 and beyond.
3
ATTACHMENT B
Response from FDOH
ATTACHMENT C
Response from Mr. Low
M I C II A E 1- R T LOW
November 12, 2024
Stuart Robinson
Director of Investigations
Office of Inspector General
P.O. Box 16568
West Palm Beach, FL 33416
[email protected]
Dear Mr. Robinson,
Thank you for providing me with an opportunity to review the report and to make
comments. The report is extensive and detailed. I intend to limit my comments to
responding to the statements made to your office by Ms. Deirdre Jacobs and Mr. Jonathan
Evans. As City Administration they hold the ultimate responsibility for the condition of the
Utility District.
Ms. Jacobs states that the first she knew of the problems was in September 2023. In fact, I
emailed her the day I received the warning letter, July 29, 2023. This was also the date that
I first became aware of the problem. Furthermore, she corrected my English and approved
the letter I wrote to the DOH in September following the meeting with the DOH that month.
The District was not aware of the exact nature of the December meeting at the DOH prior
to the meeting. Ms. Jacobs was also informed of the results of that meeting at which the
District was instructed to issue a Tier 1 notice regarding the incident at well 14. The DOH
meeting she and Mr. Evans attended took place after the mayor's press conference
regarding possible contamination in the distribution system. Ms. Jacobs was kept informed
of progress in responding to the EPA and DOH sanitary surveys as well as operational
issues in the District both verbally, at routine meetings of her team, and in writing.
Mr. Evans states that he would meet every two weeks to discuss issues individually with
me. These meetings did not commence until January 2024 and were often cancelled. Prior
to that time, it was assumed that Ms. Jacobs was keeping him appraised of the situation as
I reported directly to her. As the various engineering reports and DOH correspondence
regarding the issues became available, they were shared with city administration, and if
appropriate the elected officials, with explanatory reports prepared by me where needed.
Mr. Evans states that I had never informed him of the overall condition of the water
infrastructure and the seriousness of the situation. Since the District Board had approved
around $13M for improvements to the existing plant prior to my arrival, and the water plant
replacement project had already been awarded to the design build team prior to my start
?_ November 12,2024
date, he had to have been aware that there were issues. In addition, two engineering reports
on the state of the wells and the wastewater pumping stations were completed prior to my
arrival, when the utility was being managed by Ms. Jacobs. Both reports detailed extensive
problems in these assets with an indicated repair bill exceeding $70M.
Mr. Evans comment regarding my failure to visit the water plant, is based on hearsay
evidence, and is not true. My office is right by the water plant, and I would visit the plant,
the maintenance facilities and locations in the field on a regular basis.
Please feel free to contact me if you have any further questions.
,Sincerekr
Michael R T Low
11197 Manderly Lane • Wellington • FL 33449

cell: 561 315-8542 • e-mail [email protected]
ATTACHMENT D
Response from Mr. Doyle
November 5, 2024
Attn. Mr. Stuart Robinson

Office of Inspector General
PO Box 16568
West Palm Beach, Florida 33416
Ref: OIG Case Number: 2024-0006
Dear Mr. Robinson
Thank you for the opportunity to clarify some of the comments made within the Draft
Investigative Report 2024-0006 dated November 2024.
Attached are several comments/ clarifications that should be considered for inclusion in
the draft report.
Page 7: The Organization Chart presented on page 7 is not correct as it was presented to
me at the time of my hire. The Executive Assistant Director did not directly supervise
various divisions but similar the Executive Assistant (Luecinda Monroe), we were
branched to the left and right. The Assistant Director worked on assignments at the
discretion of the Director. The Organization Chart noted in the draft report should be
corrected. The Chart provided to me can be verified through the Executive Assistant.
Page 25: Paragraph 4: Mr. Pinkney claimed that Compliance monitoring was assigned to
Steven Doyle and David Salas. Water plant operations and compliance monitoring
were assigned to the Superintendent and the WTP Staff. The following explains the
reasoning. I was informed that the Lab Technician and Compliance Manager positions
were created by converting vacancies in the Water Treatment Plant division. Prior to
the creation of the lab technician and compliance manager positions, the task of
monitoring and reporting to the FDEP was performed through the Superintendent and
the Plant Operators. Therefore, the assignment of WTP operating maintenance,
compliance and reporting remained with the WTP Division.
Page 62: Paragraph 1, Line 4: The statement, “All of the direction that lab technicians were
receiving came from Mr. Doyle at the time.” is not correct. Compliance was assigned
to the Superintendent and Operations staff. Mr. Williams had not transferred his
telephone calls, voice messages and/or emails to me upon leaving his employment with
the City.
1|P age
Page 64: Paragraph 7: I am not aware of Mr. Pinkney informing me of well #14 in June
2023. Utility staff meetings were routinely hosted biweekly at which time Mr. Pinkney
should have brought this to everyone’s attention, including Mr. Low’s.
Page 66: Paragraph 5: Mr. Doyle was not tasked with implementing compliance but had
assigned compliance monitoring and reporting to WTP personnel. The Superintendent
and his Team of over twelve operators performed these duties prior and were
collectively the most qualified and most knowledgeable to perform the task.
Page 68, Paragraph 3: Mr. Evan’s source claimed that myself in particular, “rarely or never
present on-site at the water plant site.” Mr. Evan’s was misinformed. For example, on
many occasions, I spent days working in the lab room trying to restore or fix outdated
equipment. I physically replaced hung ceiling tiles, replaced ductwork registers, sealed
openings to improve air quality due to complaints from staff. Cleaned the filter room
on the second floor and moved available operating and maintenance manuals to
bookshelves for easy access. Worked with the electrical division to remove and repair
motor control room VFD and soft start controllers. Numerous times spent with
operators and mechanics replacing high service pump motors. Worked with staff on
replacing the WTP main generator and fuel tank system. Spent several Saturday’s
cleaning up debris from a well site located on MLK Blvd. Made periodic visits to the
WTP on Saturdays to visit both the WTP and the Water / Wastewater Divisions. I can
go on and on, but I find it difficult to believe Mr. Evan’s source.
In closing, I am unable to confirm every aspect of the report given only a few days in which
to review and comment. I appreciate the level of effort made by your staff in performing
this investigation and must assume the accuracy of its content.
As was stated in the report, I ceased my employment with the city when I could no longer
trust the information provided by others. There are a lot of good people that work for the
city, while this investigation is informative and negative, it does not reflect the positive
work performed by so many others.
Sincerely,
Steven J. Doyle
ATTACHMENT E
Response from Dr. Williams
November 14, 2024
Stuart A. Robinson
Palm Beach County Office of Inspector General
100 Australian Ave.
West Palm Beach, FL 33406
RE: Investigative Report No. 2024-0006
Mr. Robinson,
Dr. Anthony Williams has retained undersigned counsel regarding this investigation. We have
reviewed the Draft Investigative Report (“Report”). The Report states that the OIG found
sufficient information to warrant a referral to law enforcement. On behalf of Dr. Williams, the
undersigned counsel denies the OIG’s findings regarding any and all misconduct on the part
of Dr. Williams. We deny the OIG’s summaries, conclusions, and opinions regarding any and
all statements made by Dr. William’s to the OIG. We deny the veracity of the statements made
by any other individual regarding Dr. Williams. Thank you for your time and consideration.
Respectfully Submitted,
/s/ David Tarras

David Tarras, Esq.
/s/ Brian Gabriel

Brian Gabriel, Esq.

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OFFICE OF INSPECTOR GENERAL

PALM BEACH COUNTY

“Enhancing Public Trust in Government”

Insight – Oversight – Foresight

“Enhancing Public Trust in Government”

WHAT WE DID Based upon our review of information

Additionally, City Utility District staff failed to immediately report “present” E.

coli/fecal contamination or Total that is free of harmful contaminants and

This OIG Report addresses alleged Allegation (1) is supported.

City Utility District Compliance WHAT WE RECOMMEND

Mr. inkney was provided a copy of our

The City of Riviera Beach

The City operates under the Council-Mayor-Manager form of

The City of Riviera Beach Utility Special District

The City Council members serve as the five (5)

Utilities Administration provides executive oversight and administrative support to

Compliance Water Plant

Lab Technicians Water Operators

The City Utility District Water Treatment Facility

The Water Treatment Division of the City

Florida’s Safe Drinking Water Act Program

Section 403.866(5), Florida Statutes, defines “water distribution system” as those

construction of wells and the treatment plant.

resulting penalties and notice requirements.

The Federal EPA’s website states,11

Drinking water distribution systems connect water treatment plants or water

Distribution systems represent the vast majority of the physical

Currently, approximately 90 contaminants are regulated under national primary drinking

OIG Interview of Emmanuel Peters, FDOH Environmental Health Specialist

ALLEGATIONS AND FINDINGS

Federal “Safe Drinking Water Act:”

Florida Safe Drinking Water Act and Implementing Regulations

Part VI. Water Supply; Water Treatment Plants (403.850 to 403.892)

Title 62. Department of Environmental Protection

OIG Methodology for Examination of Water Testing Results

 Business for Advanced Innovations, LLC d/b/a Capzer Pharmaceuticals

OIG Interview of Lisa Fiedor, Capzer Pharmaceuticals Project Manager

samples were on ice and the temperature of the samples.

A. Staff Failed to Timely Report Test Results

OIG Laboratory Report Analysis

OIG Interview of Rafael Reyes, FDOH - Environmental Public Health and

OIG Interview of Swan Allen-Davis, City Utility District Laboratory Technician

OIG Interview of David Salas, City Utility District Lead Operator

He has a doctorate in public administration and a master’s degree in business

OIG: Would you say you're somewhat responsible?

Dr. Williams: I wouldn't say that.

OIG: You're the compliance manager that deals with this.

Dr. Williams: I understand.

Dr. Williams: Well, it wasn't my job. I assumed the responsibility.

Dr. Williams: Yeah.

Dr. Williams: Not too sure.

OIG: Is that wrong?

Dr. Williams: I was following direction.

Dr. Williams: Based on the rules, it definitely would be wrong.

OIG: You were told to do that by? ... Who in particular?

Dr. Williams: Yeah.

OIG: Was that maybe a reason why you left?

Dr. Williams: Yeah. A big reason.

B. Well #862- Staff Submitted Altered Test Results and Inaccurate

Well #862 – May 2023 Testing