•	Please enclose a copy of this completed form with your sample bottles and other paperwork. Or you may FAX the form to the Drinking Water  Program at (207) 287-4172.

STATE OF MAINE DRINKING WATER PROGRAM USE ONLY	

TEST RESULTS:  (For DWP use only)

90th  Percentile, Lead:	Note:  EPA action level = 0.015 mg/L 90th Percentile, Copper:		Note:  EPA action level = 1.3 mg/L	

Lead: Copper:	
Pass
	
Fail

Samples Collected - Insert Date(s): 	 Lab Name:
System Name:
Address:	 PWSID#:

Certification of Collection Methods

Number of Samples Required:	Compliance Period:	/	/	-	/	/	

(Place a √ next to each applicable sentence. If the sentence is not applicable, write N/A)

I hereby certify that:

 	  Each first draw tap sample for lead and copper is one liter in volume and was collected after allowing water to stand motionless in the plumbing system for at least six hours.

 	  Each first draw sample collected from a single-family residence has been collected from the cold water kitchen tap or bathroom sink tap.

 	 Each first draw sample collected from a non-residential building has been collected at an interior tap  from which water is typically drawn for consumption.

 	 Each first draw sample collected during an annual or 3-year monitoring period has been collected in the months of
June, July, August, or September.

            Each resident who volunteered to collect tap water samples from his or her home has been instructed in the proper methods for collection of lead and copper samples. I do not challenge the accuracy of those sampling results. Material distributed to residents explaining the proper collection methods, and a list of the residents who performed sampling will be provided upon request by the Drinking Water Program.

Operator Certification

I certify that I have completed both pages of this document. I certify that the information on this form is accurate to the best of my knowledge.

Signature	Operator Number	Date

Printed Name	Title

ŸŸNOTE: COMPLETE THE WORKSHEET ON THE SECOND PAGE OF THIS   DOCUMENTŸŸ
Page 1 of 2	Form 141-A

Lead and Copper Collection Site Worksheet

Lab Sample Number	

Date and Time Water Last Used	

Date and Time Sample Collected	

Sample Site Location	
Tier
(NTNC’s do not need to provide Tiers)	
D012345-001	1/1/2019, 10:50 pm	1/2/2019, 5:50 am	Example: 123 Water St, Anytown, ME - Copper pipes w/ lead solder installed 1984	1	
-002			Example: Boy’s bathroom, west wing, Hoosier building		

					

					

					
					
ŸŸ ATTACH ADDITIONAL SHEETS AS NECESSARY ŸŸ FILL IN ALL COLUMNS FOR EACH SAMPLE COLLECTED ŸŸ

Page 2 of 2	Form 141-A

Community Systems
Additional Instructions & Tier Designations
SAMPLE COLLECTION:
Each first draw tap sample for lead and copper MUST be one liter in volume and must have stood motionless in the plumbing system for at least six hours.

SAMPLE SITE SELECTION & TIER DETERMINATION:
You MUST collect from Tier 1 sites, if possible. If multi-family residences make up at least 20% of the structures served by a water system, they can be included in your Tier 1 sampling pool. Tier 2 sites can ONLY be used when all available Tier 1 sites have been exhausted. If all available Tier 1 and Tier 2 sites have been exhausted, then Tier 3 sites may be used to fulfill sampling requirements. Tier 4 sites may ONLY be used if there are not enough Tier 1, Tier 2, and Tier 3 sites to fulfill sampling requirements. Compliance samples must be collected from different locations (not take multiple samples from one location).

TIER DETERMINATION	

Tier 1	Single-family homes (including mobile homes) with:
•	copper plumbing and lead solder, built between 1982-1987
•	lead plumbing
•	lead service line
Note: Apartment buildings, condos, & residential care facilities are not Tier 1 sites.	

Tier 2	Buildings and multi-family homes (including duplexes) with:
•	copper plumbing and lead solder, built between 1982-1987
•	lead pipes
•	lead service line	

Tier 3	All other single family homes (including mobile homes) with:
•	copper pipes and lead solder built before 1982
Note: Apartment buildings, condos, & residential care facilities are not Tier 3 sites.	

Tier 4	All other buildings that don’t meet any of the above criteria. Preference must be given to residential homes/buildings over non-residential buildings.	

SITE CHANGES:
If you have changed sampling sites for any reason since the last round of lead/copper testing, please list the former location and its information on the collection site worksheet. Then indicate the new location, its tier designation, and the reason for the change. Reasons for not using a sampling site may include: the resident/sampler no longer wishes to participate, the resident/sampler cannot ensure a 6-hour standing time or is not able to follow sampling procedures.

ANNUAL AND 3-YEAR MONITORING SCHEDULES:
All samples must be collected between June 1 - September 30 in the year your samples are due.
FILLING OUT THE COLLECTION SITE WORKSHEET
The collection site worksheet must be filled out completely. Missing information may result in a failure-to-monitor violation or a failure-to-report violation. Include the lab sample number, the date/time the water was last used, the date/time the sample was collected, and the tier. For tier 3 and 4 sites, write the plumbing type and the approximate year it was installed. Ex: tier 4 – 1989, PVC.

SCHOOLS SERVED BY MUNICIPAL WATER DISTRICTS:
Schools may apply for funding to test up to 10 taps for lead and copper. For more information, visit the Drinking Water Program’s website at https://www.maine.gov/dhhs/mecdc/environmental- health/dwp/index.shtml or call (207) 287-2070.

UPDATED AS OF 2019. PLEASE READ.

Non-Transient Non-Community (NTNC)
Additional Instructions

ŸŸNTNC Systems- No tier designation is requiredŸŸ
SAMPLE COLLECTION:
Each first draw tap sample for lead and copper MUST be one liter in volume and must have stood motionless in the plumbing system for at least six hours.
If your taps are closely located (~within 10’ of each other), you will need to collect from these taps on different days to ensure the water has sat motionless for 6 hours at each tap.

SAMPLE SITE SELECTION:
Samples should be collected from taps that could reasonably be used for consumption, with a priority towards taps where consumption is more likely to occur. For example, a drinking water fountain in the art room or the main hallway would be an appropriate choice. However, a boiler room tap would not be reasonably used for consumption and therefore should not be sampled.

Compliance samples must be collected from different locations (not take multiple samples from one location). If you don’t have enough sites or are unsure if your selected sites are appropriate, call the Drinking Water Program at (207) 287-2070.
SITE CHANGES:
If you have changed sampling sites for any reason since the last round of lead/copper testing, please list the former location on the collection site worksheet. Then indicate the new location, and the reason for the change. Reasons for not using a sampling site may include: the fixture has been taken out of service.

SCHOOLS THAT ARE PUBLIC WATER SYSTEMS:
All schools that are public water systems must sample according to your lead & copper tap survey. If you do not have a tap survey or have questions about appropriate sample locations, please contact your Public Water System Inspector at (207) 287-2070.
ANNUAL AND 3-YEAR MONITORING SCHEDULES:
All samples must be collected between June 1 - September 30 in the year your samples are due.
FILLING OUT THE COLLECTION SITE WORKSHEET
The collection site worksheet must be filled out completely. Missing information may result in a failure-to-monitor violation or a failure-to-report violation. Include the lab sample number, the date/time the water was last used, and the date/time the sample was collected. Tier designations are not required for NTNC’s.

UPDATED AS OF 2019. PLEASE READ.