Form 62 555 900 – Fill Out and Use This PDF

PWS SAMPLING PLAN FOR LEAD AND COPPER TAP SAMPLES AND WATER

QUALITY PARAMETERS

See page 6 for instructions.

I. General Information

Public Water System (PWS) Name:

PWS Identification Number:					PWS Type:		Community		Non-Transient Non-Community
PWS Size:	Small	Medium		Large	Total Population Served:
Population Interval:*		A	B	C	D	E		F	G
PWS Owner:
Contact Person:								Contact Person's Title:
Contact Person's Mailing Address:
City:								State:		Zip Code:
Contact Person's Telephone Number:						Contact Person's Fax Number:
Contact Person's E-Mail Address:

*The minimum number of tap sample sites for lead and copper (LC) and water quality parameter (WQP) distribution system sample sites is based on a system's population interval, which is selected from the table below. For the purposes of this form, the population served is the sum of the number of permanent residents and the number of additional non-transient persons to whom the system is available, such as school children, office and commercial employees, and seasonal residents.

Total Population Served		Population Interval		LC Sites	WQP Sites
greater than 100,000		A	100		25
50,001 to 100,000		B	60		10
10,001 to 50,000		C	60		10
3,301 to 10,000		D	40		3
501 to 3,300		E	20		2
101 to 500		F	10		1
less than 101		G	5		1

II. Records Review

Locate and review existing plans, drawings, and reports of the water system and also those kept by county or municipal building departments or code enforcement offices to identify available sampling sites and the total number of lead service lines in the distribution system.

A.Identification of Interior Plumbing Material Types

Identify single-family and multiple-family residences and buildings that have interior plumbing containing lead pipe, copper pipe with lead solder installed after December 31, 1982, or copper pipe with lead solder installed before January 1, 1983; and identify structures with brass faucets and those with point-of-entry or point-of-use devices.

PWS SAMPLING PLAN FOR LEAD AND COPPER TAP SAMPLES AND WATER QUALITY

PARAMETERS

PWS Identification Number:

B.Identification of Lead Service Lines and Components with Lead Content

Identify the number and location of lead service lines and identify the location of water distribution system components that contain lead.

III. Materials Survey

Fill out the following Materials Survey Summary Table to summarize the results of the records review performed under Part II of this form to identify a sampling pool of lead and copper tap sampling sites.

				Type of Structure Being Served
Materials Survey Summary			SFRs		MFRs		BLDGs
				Number of Service Connections
A. Interior Plumbing Material Sites
Lead Pipe
Copper Pipe With Lead Solder Installed After 1982
Copper Pipe With Lead Solder Installed Before 1983
Brass Faucets
Point-of-Use or Point-of-Entry Treatment Devices
Lead-Lined Water Coolers
Other Lead Plumbing Components
B. Lead Service Line Sites
Total Initial Number of Lines that Are Entirely Lead and Subject
to Replacement
Partial Lead Lines	Goosenecks
	Pigtails
C. Lead Distribution System Component Sites
Service Connections Within 100 feet of Distribution System
Components Containing Lead
D. Total No. of Service Connections to Available Sampling		Sites
E. Total Number of Service Connections in Distribution System

PWS SAMPLING PLAN FOR LEAD AND COPPER TAP SAMPLES AND WATER QUALITY PARAMETERS

PWS Identification Number:

IV. Lead and Copper Tap Sampling Plan

After completing the Materials Survey, develop a Lead and Copper Tap Sampling Plan by establishing a pool of potential sampling sites. Each plan must include at least the number of sites as shown in the table in the footnote under Part I of this form. It is recommended that a system establish a sampling pool equal to 150 percent of the minimum number required to be sampled to secure a list of optional sites that can be sampled as replacement sites or as additional samples. List all identified sampling sites in the table below. Use additional copies of the table below as necessary.

				Contact Person			Home	Field		Training
						LSL	Plumbing	Verified	Site Status	Status
ID	Tier	Type	Location	Name	Phone	Y/N	Material	Y/N	S/O	Y/N

PWS SAMPLING PLAN FOR LEAD AND COPPER TAP SAMPLES AND WATER QUALITY PARAMETERS

PWS Identification Number:

V. Water Quality Parameter Sampling Plan

Fill out the following table to identify water quality parameter sampling sites. The total number of entry point sampling sites identified must equal the total number of entry points or, for consecutive systems, the total number of interconnection points, to the distribution system. The total number of distribution system sampling sites must at least equal the number of sites shown in the table in the footnote under Part I of this form. Distribution system sampling sites may be selected from among the system's microbiological sampling sites.

PWS SAMPLING PLAN FOR LEAD AND COPPER TAP SAMPLES AND WATER QUALITY

PARAMETERS

PWS Identification Number:

VI. Certification

A.Site Selection Criteria

Whenever possible, lead and copper tap sample plans must include tier 1 sites exclusively. Explain the selection of other than tier 1 sites; and if sites were changed from one monitoring period to another, explain why the sites were changed (attach additional pages if necessary).

B.Lead Service Line Sites

When lead service line sites are identified, they must comprise at least 50 percent of the selected samples. Explain why the percentage of lead service line sites is not at least 50 percent of the required number of sampling sites (attach additional pages if necessary).

C.Water Quality Parameter Sampling Plan

If any WQP distribution system sampling sites are not also microbiological sampling sites, explain how the selected WQP distribution system sampling sites represent water quality throughout the distribution system based on the distribution of population, the different sources of water and treatment methods, and an even distribution of sampling throughout the six-month sampling period (attach additional sheets as necessary).

I am duly authorized to sign this form on behalf of the PWS identified in Part I of this form. I certify that the information provided on this form is true and accurate to the best of my knowledge and belief. I certify that the information listed and checked in Part II of this form was used to perform the materials survey in order to identify the total number of lead service lines in the PWS and to establish the sampling pool and sampling plans. I also certify that the number of lead service lines reported in Part III of this form is the total known number of lead service lines in the PWS and that the selected sampling sites in Part IV of this form are the highest risk sites available.

Signature and Date

Printed or Typed Name

Title

PWS SAMPLING PLAN FOR LEAD AND COPPER TAP SAMPLES AND WATER QUALITY

PARAMETERS

INSTRUCTIONS: This form shall be completed and submitted by community water systems (CWSs) and by non-transient non- community water systems (NTNCWSs). Complete all parts of this form, attach any maps and written narrative describing the sampling plan, and submit the completed form and any attachments to the appropriate Department of Environmental Protection (DEP) District Office or Approved County Health Department (ACHD) 30 DAYS PRIOR TO THE BEGINNING OF A SIX-MONTH MONITORING PERIOD FOR LEAD AND COPPER IN DRINKING WATER. All information provided on this form shall be typed or printed in ink. The DEP District Office or ACHD will notify a system of approval of a Sampling Plan in writing, which will provide the system notice to proceed. Submit a revised Sampling Plan using this form if any changes in the selection of sampling sites must be made. When no changes have been made, no resubmission is necessary prior to sampling during the next six-month sampling period.

The following specific instructions are for the table in Part III of this form.

In A and B, show, by type of structure being served (i.e., single-family residences [SFR], multiple-family residences [MFR], or other buildings [BLDG]), the number of service connections to sites having the listed interior plumbing material characteristics or the listed service line characteristics. In C, show, by type of structure being served, the number of service connections within 100 feet of distribution system components containing lead. In D, show, by type of structure being served, the total number of service connections to available sampling sites. In E, show, by type of structure being served, the total number of service connections in the distribution system.

The following specific instructions are for the table in Part IV of this form.

ID. Enter a site identification number of up to three digits.

TIER. Enter the tier number of each site. Lead and copper tap sampling sites are categorized as tier 1, for the highest risk, to tier 2, 3, or 4 for successively lower risks. The tier categories are different for CWSs and NTNCWSs. For CWSs, tier 1 sites are single- family residences or child care facilities that contain either: copper pipe with lead solder installed after December 31, 1982, lead pipe, or a lead service line. Multiple-family residences are tier 1 when they comprise at least 20 percent of the structures served by the system. For CWSs, tier 2 sites include buildings and multiple-family residences that contain: copper pipe with lead solder installed after December 31, 1982, lead pipe, or a lead service line. For CWSs, tier 3 sites consist of single-family residences that contain copper pipe with lead solder installed before January 1, 1983. For CWSs, tier 4 sites are those that are identified as susceptible to lead or copper contamination but not belonging to one of the other tiers. For NTNCWSs, tier 1 sites are buildings that contain: copper pipe with lead solder installed after December 31, 1982, lead pipe, or a lead service line. For NTNCWSs, tier 2 sites are buildings that contain copper pipe with lead solder installed before January 1, 1983. For NTNCWSs, tier 3 sites are those identified as susceptible to lead or copper contamination and are the same as CWS tier 4 sites. When too few tier 1 sites are identified, tier 2 sites must be located to develop the sampling plan and so on through tiers 3 and 4.

TYPE, LOCATION, and CONTACT PERSON. Enter the type of structure in the Type column. Site types are identified as a single-family residence (SFR), a multiple-family residence (MFR), or a building (BLDG). Enter the street address of the site in the Location column and the name and phone number of the building or residence owner in the Contact Person column.

LSL and HOME PLUMBING MATERIAL. Enter a "Y" in the LSL column to identify a site with a lead service line. The plumbing material must be identified for each site in the Home Plumbing Material column. Enter one of the following:

•"Pb1" to identify a site with lead solder installed after December 31, 1982;

•"Pb2" to identify a site with lead solder installed before January 1, 1983;

•"LP" to identify a site with lead pipe;

•"BF" to identify tier 4 sites (tier 3 for NTNCWSs) that have brass faucets;

•"WC" to identify tier 4 sites that have water coolers with lead content;

•"POE" or "POU" to identify tier 4 sites that have a point-of-entry or point-of-use treatment device, respectively; or

•"LC" to identify a tier 4 site within 100 feet of a lead component in the distribution system.

FIELD VERIFIED, SITE STATUS, and TRAINING STATUS. Show if the site's home plumbing or service line material has been field verified by a "Y" in the Field Verified column. Sites selected for sampling should be indicated by entering an "S" in the Site Status column. Optional sites are identified by an "O." To be a selected site, there must be an agreement with the site building owner to sample himself or to have the site sampled by the system. All homeowners who will sample at the selected sites must receive training in sampling procedures. Indicate which homeowners have received training by a "Y" in the Training Status column.

The following specific instructions are for the table in Part V of this form.

ID NUMBER. Use a two-digit number as an identification number.

LOCATION. The street address should be given as the site location.

TARGET DATES. List target sampling dates for the two required sampling rounds to demonstrate how sampling will evaluate seasonal water quality differences.