/ John R. Kasich, Governor
Mary Taylor, Lt. Governor
Craig W. Butler, Director
PWS NAME: / DRINKING WATER PROGRAM – COMPLIANCE NOTIFICATION
PWSID:OH / DATE:
COUNTY: / SUBMITTED BY:

In accordance with Ohio Administrative Code (OAC) Rule 3745-81-86 (D)(4)(c), no water system is eligible to monitor for lead and copper once every three years (“triennially”) without applying to, and receiving written approval from, the director of Ohio EPA.

Documentation provided herein to request a reduction to triennial monitoring (select at least one for eligibility):

Demonstrates that the water system’s tap water lead and copper levels, computed pursuant toOAC Rule 3745-81-80, are less than or equal to 0.005 milligrams per liter and 0.65 milligrams per liter, respectively, for the five most recent consecutive monitoring periods. List the monitoring periods you are using in this application:

Type of Monitoring Period
(triennial, annual or 6-month) / Corresponding Dates for Monitoring Period / Lead 90thPercentile / Copper 90th Percentile

Demonstrates that the water systemhas maintained the range of values for water quality control parameters reflecting optimal corrosion control treatmentas designated by the director pursuant to OAC Rule 3745-81-82(F), for the five most recent consecutive monitoring periods. Attach a summary of the water quality parameter data, list the monitoring periods you are using in this application, and give date water quality parameters were established:

Type of Monitoring Period
(triennial, annual or 6-month) / Corresponding Dates for Monitoring Period
Date Director established Water Quality Parameters

Demonstrates the water system does not own service lines, fixtures, pipe or solder that contains lead.Attach completed verification form.

Signature of Responsible Person Date
Printed Name and Title of Responsible Person
OHIO EPA USE ONLY
Received:
Reviewed:
Comments:

Direct all questions regarding this application to:

Northwest District
Your NWDO inspector
(419) 352-8461 / Northeast District
Your NEDO inspector
(330) 963-1200
Southwest District
Jeff Stark
(937) 285-6357 / Southeast District
Your SEDO inspector
(740) 385-8501
Central District
Katie Anderson
(614) 728-3778

Send your completed triennial lead and copper monitoring application to:

Northwest District
Ohio EPA – NWDO
Division of Drinking and Ground Waters
347 North Dunbridge Road
Bowling Green, Ohio 43402 / Northeast District
Ohio EPA - NEDO
Division of Drinking and Ground Waters
2110 East Aurora Road
Twinsburg, Ohio 44087
Southwest District
Ohio EPA – SWDO
Division of Drinking and Ground Waters
401 East Fifth Street
Dayton, Ohio 45402
Attn: DOCC / Southeast District
Ohio EPA – SEDO
Division of Drinking and Ground Waters
2195 Front Street
Logan, Ohio 43138
Central District
Ohio EPA – CDO
Division of Drinking and Ground Waters
P.O. Box 1049
Columbus, Ohio 43216-1049
Attn: Katie Anderson

Revised 08/24/2018