"Community Public Water System Request for Lead and Copper Sample Site Plan Changes" - North Dakota

Community Public Water System Request for Lead and Copper Sample Site Plan Changes is a legal document that was released by the North Dakota Department of Health - a government authority operating within North Dakota.

Form Details:

  • Released on December 1, 2016;
  • The latest edition currently provided by the North Dakota Department of Health;
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Download "Community Public Water System Request for Lead and Copper Sample Site Plan Changes" - North Dakota

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COMMUNITY PUBLIC WATER SYSTEM REQUEST FOR LEAD AND COPPER SAMPLE SITE PLAN CHANGES
NORTH DAKOTA DEPARTMENT OF HEALTH
DIVISION OF MUNICIPAL FACILITIES
(12-2016)
Instructions: A valid reason must be provided for all proposed changes (e.g.; house gone, plumbing or service line replaced, homeowner unwilling to participate).
Replacement sites- A new site must meet the same Tier criteria as the old site it is replacing unless no sites are available which match. If no matching sites can be
located, then the highest risk Tier site available must always be selected.*
Additional sites - All sites added to the plan must be of the highest risk Tier available.* If not replacing old sites simply leave that line blank.
Section I: Public Water System (PWS) Information
PWS Name:
PWS Number: (ex. ND1234567)
PWS Authorized Signature:
Date:
Phone:
Section II: Site Information
Interior Structure Plumbing
Service Line
Type of Site (
one)
(
all that apply)
(
one)
Copper
Reason for Change
Sample Site Address
Copper
Single
Multiple
Lead
Built
No
Other
Built 1983
Lead
Family
Family
Pipes
BEFORE
Lead
Building
to1988
Structure
Residence
1983
Old:
New:
Old:
New:
Old:
New:
Tier 1 –
*Highest Risk
Single family structure with copper pipes and lead solder built 1983 to 1988, or lead pipes, and/or a lead service line.
Tier 2 –
Multiple family residence or building with copper pipes and lead solder built 1983 to 1988, or lead pipes, and/or a lead service line.
Tier 3 –
Single family structure with copper pipes and lead solder built before 1983.
Representative –
Lowest Risk
Site containing materials which are representative of what is found throughout the distribution system. Can only be used if not enough
Tier sites present.
Make as many copies as necessary to provide all sample site changes. Send the completed form(s) to:
Division of Municipal Facilities
918 E. Divide Ave., 3rd Floor
Bismarck, ND 58501-1947
COMMUNITY PUBLIC WATER SYSTEM REQUEST FOR LEAD AND COPPER SAMPLE SITE PLAN CHANGES
NORTH DAKOTA DEPARTMENT OF HEALTH
DIVISION OF MUNICIPAL FACILITIES
(12-2016)
Instructions: A valid reason must be provided for all proposed changes (e.g.; house gone, plumbing or service line replaced, homeowner unwilling to participate).
Replacement sites- A new site must meet the same Tier criteria as the old site it is replacing unless no sites are available which match. If no matching sites can be
located, then the highest risk Tier site available must always be selected.*
Additional sites - All sites added to the plan must be of the highest risk Tier available.* If not replacing old sites simply leave that line blank.
Section I: Public Water System (PWS) Information
PWS Name:
PWS Number: (ex. ND1234567)
PWS Authorized Signature:
Date:
Phone:
Section II: Site Information
Interior Structure Plumbing
Service Line
Type of Site (
one)
(
all that apply)
(
one)
Copper
Reason for Change
Sample Site Address
Copper
Single
Multiple
Lead
Built
No
Other
Built 1983
Lead
Family
Family
Pipes
BEFORE
Lead
Building
to1988
Structure
Residence
1983
Old:
New:
Old:
New:
Old:
New:
Tier 1 –
*Highest Risk
Single family structure with copper pipes and lead solder built 1983 to 1988, or lead pipes, and/or a lead service line.
Tier 2 –
Multiple family residence or building with copper pipes and lead solder built 1983 to 1988, or lead pipes, and/or a lead service line.
Tier 3 –
Single family structure with copper pipes and lead solder built before 1983.
Representative –
Lowest Risk
Site containing materials which are representative of what is found throughout the distribution system. Can only be used if not enough
Tier sites present.
Make as many copies as necessary to provide all sample site changes. Send the completed form(s) to:
Division of Municipal Facilities
918 E. Divide Ave., 3rd Floor
Bismarck, ND 58501-1947