Lead Public Education Verification

Lead Public Education Verification

Nontransient Noncommunity and Small Community1 Public Water Systems

Public Water System Name: ______

Public Water System ID Number: ______County: ______

A public water system that has an action level exceedance (ALE) is to make an analysis of laboratory results available to all consumers served by the system, deliver public education materials and provide information to consumers about the availability of health screenings and blood lead level testing in the areas served by the water system no later than thirty business days after receipt of sample results. Submit this completed form and a copy of the public education materials to your Ohio EPA district office within five business days of completion of the public education activity. Retain a copy of this report in your files with supporting documentation for a minimum of 12 years.
Required methods of Public Education for Nontransient Noncommunity and Small Community1 Public Water Systems / Distribution Date
Post informational posters on lead in drinking water in a public place or common area in each of the buildings served by the system.
(Required to be repeated once during each calendar year in which the system exceeds the lead action level.) / Date first posted: ______
Distribute information via pamphlets, brochures or electronic transmission on lead in drinking water to each person served by the nontransient noncommunity water system.
(Required to be repeated once during each calendar year in which the system exceeds the lead action level.) / Date of delivery: ______
Additional requirement for schools, day cares, nursing homes or correctional institutions - Parents, legal guardians or persons granted power of attorney shall be directly provided Public Education materials (e.g. newsletter, e-mail notice or direct mailing). / Method(s) ______
______
Date(s) ______

The attached Public Education material is representative of what was issued.

I hereby certify that the Public Education material was distributed to all persons served by the water system. Distribution was made by the methods and dates indicated above.

______

Signature of Responsible Official Date

______

Printed Name Title of Responsible Official

For Ohio EPA use only PE verification form received date: ______
PE on time: ______PE late: ______PE Acceptable: ______PE Not Acceptable: ______

1 Small community systems covered under this verification form include facilities, such as a prison or a hospital, where the population served is not capable of or is prevented from making improvements to plumbing and the system provides water as part of the cost of services and does not separately charge for water consumption.

(Revised 09/21/17)