Notes: Example entries are shown in the table below to help you properly complete this form. Date Site Lead Tier Added Site Customer Name and Year Plumbing Materials in Service 1, 2, 3 Justification for designation of Comments Explaining (A) / Number Physical Address Built Structure Line (LSL)? or Tier 1, Tier 2, Tier 3 or Other Change Deleted Yes / No Other (D) Examples for Community Water Systems: Lead solder confirmed by swab test; Added to replace Location 001 120 Maple Lane, Anytown, MS 1985 Copper pipe with lead solder Yes 1 3/9/16 (A) LSL confirmed by excavation 024; LSL discovered House demolished in Feb. 024 241 Lakeside Blvd, Anytown, MS 1984 Copper pipe No 1 Built in 1984 with copper pipe 3/7/16 (D) 2016 Examples for Non-transient non-community Systems: 001 Breakroom in Main Building 1984 Copper pipe with lead solder No Tier 1 Pipes are joined with lead solder 5/3/93 (A) Added at LCR inception Added due to facility 005 Restroom in New Wing 1988 PVC pipe No Other Built after 1985 with plastic pipe 8/7/02 (A) expansion
Notes: Example entries are shown in the table below to help you properly complete this form. Site Number Customer Name and Physical Address Year Built Plumbing Materials in Structure Lead Service Line (LSL)? Yes / No Tier 1, 2, 3 or Other Justification for designation of Tier 1, Tier 2, Tier 3 or Other Date Site Added (A) / Deleted (D) Comments Explaining Change Examples for Community Water Systems: 001 120 Maple Lane, Anytown, MS 1985 Copper pipe with lead solder Yes 1 Lead solder confirmed by swab test; LSL confirmed by excavation 3/9/16 (A) Added to replace Location 024; LSL discovered 024 241 Lakeside Blvd, Anytown, MS 1984 Copper pipe No 1 Built in 1984 with copper pipe 3/7/16 (D) House demolished in Feb. 2016 Examples for Non-transient non-community Systems: 001 Breakroom in Main Building 1984 Copper pipe with lead solder No Tier 1 Pipes are joined with lead solder 5/3/93 (A) Added at LCR inception 005 Restroom in New Wing 1988 PVC pipe No Other Built after 1985 with plastic pipe 8/7/02 (A) Added due to facility expansion
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