Lead & Copper Forms & Templates

For use by COM and NTNC. Checklist form with steps to follow before, during, and after sampling. Rev. Feb 2019

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. March 2019

For use by NTNC. Chain of Custody form with sampling instructions for certified operator or facility representative for sampling. Rev. March 2019

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

For use by COM and NTNC. Rev. Jul. 2020

For use by COM and NTNC. Rev. Jul. 2020

For use by COM and NTNC.

For use by COM. Form to certify that your sampling plan includes the highest possible tier class. Rev. Feb 2019

For use by COM. Consumer notification form for schools. Rev. March 2019

For use by COM. Consumer notification form for homeowner results.

For use by NTNC. Consumer notification form with instructions for NTNC systems. Rev. Feb 2019

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

For use by COM and NTNC. Rev. Feb 2019

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).

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).

For use by COM and NTNC.

For use by COM. Template letter soliciting participation for sampling. Rev. Feb 2019

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.