LEAD AND COPPER SAMPLING POOL - DETAILS Page _____ of _____ (use additional sheets as necessary) System Name: Water System Number: County: Date: System Type: (√ check box) Population: Existing Corrosion Control Number of Samples Required for Treatment: Standard Monitoring: _________ Community or Non-transient non-community Prepared by: (Print Name) Signature: Phone: __________________ System Affiliation: (√ check box) ____________________ Owner or Responsible person . Notes: To help you properly complete this form, example entries are shown for this form on our website at For water systems with Lead Service Lines (LSLs), half of all sites sampled must contain LSLs as per §141.86(a)(8). LSL on LSL on System’s Date Customer’s Physical Address Tier Added Side? Site Side? Location (Street and City for CWS) Year Plumbing Materials in 1, 2, Tier Designation (A) or Comments Explaining Added (water main to (meter to customer’s Code or Built Structure 3 or Justification Deleted Change customer’s or building) Physical Location (for NTNC) meter) Other (D) Deleted Yes / No Yes / No
LEAD AND COPPER SAMPLING POOL - DETAILS Page _____ of _____ (use additional sheets as necessary) System Name: Water System Number: County: Date: System Type: (√ check box) Community or Non-transient non-community Population: Existing Corrosion Control Treatment: Number of Samples Required for Standard Monitoring: _________ Prepared by: (Print Name) Signature: Phone: __________________ ____________________ System Affiliation: (√ check box) Owner or Responsible person Notes: To help you properly complete this form, example entries are shown for this form on our website at . For water systems with Lead Service Lines (LSLs), half of all sites sampled must contain LSLs as per §141.86(a)(8). Location Code Physical Address (Street and City for CWS) or Physical Location (for NTNC) Year Built Plumbing Materials in Structure LSL on System’s Side? (water main to customer’s meter) Yes / No LSL on Customer’s Side? (meter to customer’s building) Yes / No Tier 1, 2, 3 or Other Tier Designation Justification Date Site Added or Deleted Added (A) or Deleted (D) Comments Explaining Change
2016_Lead%20and%20Copper%20Sampling%20Pool%20-%20Details%20spreadsheet.docx