Date: PWS Name: PWSID No.: Address: Phone: Fax: Email: Contact Person: Title: Population: Minimum Number of Samples: V. Community Water System Sample Site ACTIVATION Use the following graph to determine the accurate tier. Multiple Family Residence/ Tier Single Family Residence Buildings Copper pipes w/ lead solder installed AFTER 1982 1 - Lead Pipes Lead service lines Copper pipes w/ lead solder installed AFTER 1982 2 - Lead Pipes Lead service lines Copper pipes with lead solder 3 - installed BEFORE 1983 Copper pipes with lead solder Non-Tier Non-copper and non-lead installed BEFORE 1983 Non-copper and non-lead Street (or 911) Address: Type of Structure: Type of Plumbing: Tier: Reason for not using a tier-1 sample site: Street (or 911) Address: Type of Structure: Type of Plumbing: Tier: Reason for not using a tier-1 sample site: Street (or 911) Address: Type of Structure: Type of Plumbing: Tier: Reason for not using a tier-1 sample site: Street (or 911) Address: Type of Structure: Type of Plumbing: Tier: Reason for not using a tier-1 sample site: Street (or 911) Address: Type of Structure: Type of Plumbing: Tier: Reason for not using a tier-1 sample site:
Date: PWS Name: PWSID No.: Address: Phone: Fax: Email: Contact Person: Title: Population: Minimum Number of Samples: V. Community Water System Sample Site ACTIVATION Use the following graph to determine the accurate tier. Tier Single Family Residence Multiple Family Residence/ Buildings 1 Copper pipes w/ lead solder installed AFTER 1982 Lead Pipes Lead service lines - 2 - Copper pipes w/ lead solder installed AFTER 1982 Lead Pipes Lead service lines 3 Copper pipes with lead solder installed BEFORE 1983 - Non-Tier Non-copper and non-lead Copper pipes with lead solder installed BEFORE 1983 Non-copper and non-lead Street (or 911) Address: Type of Structure: Type of Plumbing: Tier: Reason for not using a tier-1 sample site: Street (or 911) Address: Type of Structure: Type of Plumbing: Tier: Reason for not using a tier-1 sample site: Street (or 911) Address: Type of Structure: Type of Plumbing: Tier: Reason for not using a tier-1 sample site: Street (or 911) Address: Type of Structure: Type of Plumbing: Tier: Reason for not using a tier-1 sample site: Street (or 911) Address: Type of Structure: Type of Plumbing: Tier: Reason for not using a tier-1 sample site: