Office of Drinking Water
Lead and Copper Monitoring Sample Site and Certification Form
Revised November 2014 Amended Form 141-A
Office of Drinking Water
Lead and Copper Monitoring Sample Site and Certification Form
Revised November 2014 Amended Form 141-A
Office of Drinking Water
Lead and Copper Monitoring Sample Site and Certification Form
Water System Name: Click here to enter text.
PWSID: Click here to enter text.
Contact Person: Click here to enter text.
Title: Click here to enter text.
Date Certified: Click here to enter text.
☐CWS ☐NTNCWS
Number of People Served:
☐ Less than 100 ☐ 101 to 500
☐ 501 to 3,300 ☐ 3,301 to 10,000
☐ 10,001 to 100,000 ☐ More than 100,000
Revised November 2014 Amended Form 141-A
Office of Drinking Water
Lead and Copper Monitoring Sample Site and Certification Form
Revised November 2014 Amended Form 141-A
Office of Drinking Water
Lead and Copper Monitoring Sample Site and Certification Form
Signature:
Results of monitoring
Revised November 2014 Amended Form 141-A
Office of Drinking Water
Lead and Copper Monitoring Sample Site and Certification Form
# of samples required
# of samples submitted
90th Percentile Pb (ppm)
90th Percentile Cu (ppm)_
Revised November 2014 Amended Form 141-A
Office of Drinking Water
Lead and Copper Monitoring Sample Site and Certification Form
Revised November 2014 Amended Form 141-A
Office of Drinking Water
Lead and Copper Monitoring Sample Site and Certification Form
If the State has informed you that it will calculate your 90th percentile levels, you do not need to submit the 90th percentile calculations. However, you must still provide your sample results to the State by the deadline that they have specified.
Water quality parameter sample results, if required, must be attached to this form.
Revised November 2014 Amended Form 141-A
Office of Drinking Water
Lead and Copper Monitoring Sample Site and Certification Form
# of WQP tap samples required
# of WQP tap samples submitted
# of entry point samples required
# of entry point samples submitted
Revised November 2014 Amended Form 141-A
Office of Drinking Water
Lead and Copper Monitoring Sample Site and Certification Form
Change in Sampling Site
Revised November 2014 Amended Form 141-A
Office of Drinking Water
Lead and Copper Monitoring Sample Site and Certification Form
Original site
Street Address: Click here to enter text.
City or Town: Click here to enter text.
Targeting Criteria Tier: ☐1 ☐2 ☐ 3
New site
Street Address: Click here to enter text.
City or Town: Click here to enter text.
Targeting Criteria Tier: ☐1 ☐2 ☐ 3
Revised November 2014 Amended Form 141-A
Office of Drinking Water
Lead and Copper Monitoring Sample Site and Certification Form
Distance between sites (approximate): Click here to enter text.
Reason for change (attach additional pages if necessary)
Revised November 2014 Amended Form 141-A