Lead & Copper Forms and Templates

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Instructions for using version 1.0.3 of the Service Line Inventory Excel Workbook

Enrollment instructions for PWSs that want to use the MA-LSLI app.

Form for PWSs to begin to document their strategy to remove all lead service lines. PWSs should use this form to document their plans until MassDEP LCRR regulations and programs are finalized.

Form for certifying that a PWS has no lead service lines.

The following survey should be submitted by December 15th, 2023. The survey contains questions pertaining to your system's service line inventory submission timeline.

For use by COM and NTNC. Checklist form with steps to follow before, during, and after sampling. Rev. May 2023

For use by COM and NTNC. Template form to certify to MassDEP that persons served by the taps tested have been notified of the results. Rev. Feb 2020

For use by COM. Chain of Custody form with sampling instruction for home residents. Rev. Apr. 2023.

For use by NTNC. Chain of Custody form with sampling instructions for certified operator or facility representative for sampling. Rev. Apr. 2023.

For use by COM and NTNC.

For use by COM and NTNC.

For use by COM and NTNC. Form to submit lead and copper sampling results.

For use by COM and NTNC. For systems required to collect more than 5 samples. Rev. Feb 2019

For use by COM and NTNC. For systems required to collect 5 samples. Rev. Feb 2019

Instructions for filling out the LCR-LOC-MOD form. Current version of the LCR-LOC-MOD form is ver. 1.4.4)

For use by COM. Form to certify that your sampling plan includes the highest possible tier class. Rev. Apr. 2023.

For use by COM. Consumer notification form for schools. Rev. May 2023.

For use by COM. Consumer notification form for homeowner results. Rev. June 2023.

For use by NTNC. Consumer notification form with instructions for NTNC systems. Rev. May 2023.

For use by COM and NTNC. Lead and copper material survey factsheets with instructions. Rev. May 2023

For use by COM and NTNC. Rev. May 2023

Lead public education brochure template to be used by PWS without corrosion control treatment to notify customers when the PWS exceeds the 90th percentile for lead based on tap water samples collected in accordance with 310 CMR 22.06B(7). Rev. May 2023.

Lead public education brochure template to be used by PWS with corrosion control treatment to notify customers when the PWS exceeds the 90th percentile for lead based on tap water samples collected in accordance with 310 CMR 22.06B(7). Rev. May 2023.

For use by COM and NTNC. Rev. May 2023.

For use by COM. Template letter soliciting participation for sampling. Rev. May 2023

This template is for use by PWS to send notices to households of their lead results. It is for households where the PWS' 90th percentile level in their most recent sampling round is below the action level and the household’s drinking water lead sample is greater than 15 ppb.

This template is for use by PWS to send notice to households of their lead results. It is for households where both the PWS' 90th percentile level in their most recent sampling round and the household’s drinking water lead sample result are greater than 15 ppb.

This template if for use by PWS to confirm distribution of the required "Exceedance of Lead Level at Households" information to: EPA, MassDEP, and the Local Board of Health.