Asbestos Waiver Request & Construction Materials Report
Note: This form must be completed by the system owner or designated person in responsible charge.
Water System Name: / Water System Number:Owner: / County:
Address: / City: / State and Zip Code:
This form is to be used to report the construction materials exposed to the drinking water in the piping system of your public water supply system to the Public Water Supply Section as per 15A NCAC 18C Section .1507 (§141.42). Please check each box indicating the type of construction materials present in your distribution system, including home plumbing. If any other material is present in the system, list the material in the field marked "Other". Complete and return the form to the Lead and Copper Rule Manager at the address located at the bottom of the page.
Please keep a copy for your records.
Construction Materials Report□ Lead pipe, piping with lead-lined interior, or lead joint pipe in the distribution mains / □ Copper from piping and alloys, service lines and home plumbing
□ Lead service lines (water main to meter and/or meter to customer’s building) / □ Glass
□ Lead goosenecks/pigtails / □ Coal tar lined pipes and tanks
□ Lead from solder, caulking, alloys and home plumbing / □ Asbestos cement pipe
□ Galvanized piping, service lines, and home plumbing / □ Vinyl lined asbestos cement pipe
□ Brass / □ Cement (non-asbestos)
Ferrous piping materials
□ Steel
□ Cast Iron
□ Ductile Iron / Plastic
□ PVC
□ Polybutylene
□ Polyethylene or Cross-linked polyethylene (PEX)
Other:
Form Completed By: (Print Name) / Signature: / Date:
Phone: / Email: / System Affiliation: (√ check box)
Owner or Responsible person
Return this form to: Public Water Supply Section, Attention: Lead and Copper Rule Manager,
1634 Mail Service Center, Raleigh, NC 27699-1634