"Lead & Copper in Schools Maintenance Checklist" - Massachusetts

Lead & Copper in Schools Maintenance Checklist is a legal document that was released by the Massachusetts Department of Environmental Protection - a government authority operating within Massachusetts.

Form Details:

  • Released on April 1, 2016;
  • The latest edition currently provided by the Massachusetts Department of Environmental Protection;
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Download "Lead & Copper in Schools Maintenance Checklist" - Massachusetts

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Massachusetts Department of Environmental Protection
Bureau of Water Resources – Drinking Water Program
Lead & Copper in Schools Maintenance Checklist
Instructions:
This checklist should be completed for each school or childcare facility (Early Education and Care program) in the Commonwealth.
This checklist is designed to help determine if Lead or Copper is likely to be a problem in your facility’s drinking water and will enable
you to determine appropriate remediation actions if needed.
Important:
A. General
When filling out
forms on the
computer, use
Name of School or Early Education and Care Facility (EEC)
only the tab key
to move your
cursor - do not
use the return
School District or EEC Headquarters
EEC Regional Office
key.
Street Address of School or EEC Facility
City/Town
Zip Code
Contact Person’s Name at School, Program, or Facility (for LCCA Program)
Phone #
Email Address
Is part of your Facility at another location (other than the one listed above)?
YES
NO
If yes, please provide the following information:
Name of off-site facility/building
Street Address
City/Town
Zip Code
Is your school/facility a “Hosted” facility, i.e., does your school/facility share the
YES
NO
space it occupies with another school/facility that is also submitting a Lead & Copper
IF NO, SKIP TO SECTION C
in Schools Maintenance Checklist?
B. Host Facility Information
Name of “Host” facility that your facility is located within.
Contact Person’s Name
Phone #
Email Address
SKIP TO SECTION F
C. Public Water System
YES
NO
Is your school/facility a Public Water System (PWS), i.e., do you have your own well
which supplies 25+ people per day?
IF YES, SKIP TO SECTION E
D. Drinking Water Practices
(2005-Present)
Have you previously submitted a lead & copper checklist to MassDEP?
YES
NO
If yes, what was the date of the last lead & copper checklist submitted?
mm/dd/yyyy
Has your public water system (PWS – supplying water to your facility) collected lead
YES
NO
& copper samples at your school/facility?
If yes, what was the date of the last sample?
mm/dd/yyyy
04/2016
checklist.doc •
Page 1 of 3
Massachusetts Department of Environmental Protection
Bureau of Water Resources – Drinking Water Program
Lead & Copper in Schools Maintenance Checklist
Instructions:
This checklist should be completed for each school or childcare facility (Early Education and Care program) in the Commonwealth.
This checklist is designed to help determine if Lead or Copper is likely to be a problem in your facility’s drinking water and will enable
you to determine appropriate remediation actions if needed.
Important:
A. General
When filling out
forms on the
computer, use
Name of School or Early Education and Care Facility (EEC)
only the tab key
to move your
cursor - do not
use the return
School District or EEC Headquarters
EEC Regional Office
key.
Street Address of School or EEC Facility
City/Town
Zip Code
Contact Person’s Name at School, Program, or Facility (for LCCA Program)
Phone #
Email Address
Is part of your Facility at another location (other than the one listed above)?
YES
NO
If yes, please provide the following information:
Name of off-site facility/building
Street Address
City/Town
Zip Code
Is your school/facility a “Hosted” facility, i.e., does your school/facility share the
YES
NO
space it occupies with another school/facility that is also submitting a Lead & Copper
IF NO, SKIP TO SECTION C
in Schools Maintenance Checklist?
B. Host Facility Information
Name of “Host” facility that your facility is located within.
Contact Person’s Name
Phone #
Email Address
SKIP TO SECTION F
C. Public Water System
YES
NO
Is your school/facility a Public Water System (PWS), i.e., do you have your own well
which supplies 25+ people per day?
IF YES, SKIP TO SECTION E
D. Drinking Water Practices
(2005-Present)
Have you previously submitted a lead & copper checklist to MassDEP?
YES
NO
If yes, what was the date of the last lead & copper checklist submitted?
mm/dd/yyyy
Has your public water system (PWS – supplying water to your facility) collected lead
YES
NO
& copper samples at your school/facility?
If yes, what was the date of the last sample?
mm/dd/yyyy
04/2016
checklist.doc •
Page 1 of 3
Massachusetts Department of Environmental Protection
Bureau of Water Resources – Drinking Water Program
Lead & Copper in Schools Maintenance Checklist
Beside your PWS samples, has your school/facility or another party hired by your
YES
NO
facility taken lead & copper sample(s) in the last 12 months?
If yes, what was the date of the last sample?
mm/dd/yyyy
If yes, who conducted the sampling?
Do you have a plumbing profile of your school or facility? (e.g. a map of all the
YES
NO
plumbing lines and equipment with the type of material noted.)
Has your school or facility prepared a sampling plan showing all fixtures, their ID
YES
NO
numbers, and the last date they were sampled for lead or copper?
Do you keep your lead & copper testing results and other records in a file onsite?
YES
NO
If no, where are the records kept?
Name of off-site facility/building
Street Address
City/Town
Zip Code
Has every LCCA fixture at the location been sampled for lead & copper at least once?
YES
NO
Did any samples exceed the Action Level for lead (0.015 ppm) or copper (1.3 ppm)
YES
NO
If yes, check all remediation actions taken:
Fixtures Removed
Retesting
Re-piping
Flushing
Bottled Water (Temporary)
Bottled Water (Permanent)
Treatment Unit Installed
Notice Sent to Parents
Does your school or facility use bottled water as your main source of drinking water
YES
NO
for students?
If yes, are students required to bring bottled water with them to your
YES
NO
school or facility?
Does your school or facility use bottled water as your main source of drinking water
YES
NO
for staff?
Does your school or facility use bottled water as your main source of drinking water
YES
NO
for visitors?
Does your facility have water coolers?
YES
NO
If yes, has your school or facility checked the bands and models of water coolers,
and compared them to the listing of “banned” water coolers in Appendix E of the EPA
YES
NO
3Ts Toolkit.
Have all EPA “banned” water coolers found at your facility been disconnected and removed? Disconnecting
“banned” water coolers is only an interim measure. They must be removed from the facility so they are never
inadvertently reconnected in the future.
Disconnected and removed
Disconnected but not removed
Neither disconnected nor removed
No “banned” water coolers found on site
Is the service line a “lead” service line? The service line is the pipe leading from the
YES
NO
PWS main line in the street outside your facility into your facility.
Describe your current school/facility lead & copper in drinking water program. Please provide a short description in
the box provided and attach a copy.
04/2016
checklist.doc •
Page 2 of 3
Massachusetts Department of Environmental Protection
Bureau of Water Resources – Drinking Water Program
Lead & Copper in Schools Maintenance Checklist
E. Co-Located Facilities
Do you have any other schools, programs (collaborative, special education, etc.) or
Early Education and Care Facilities (covered by your checklist and sampling plan)
YES
NO
within your school or facility?
If yes, provide the following information about the school, program, or facility.
Name of School, Program, or Facility
Contact Person’s Name
Phone #
Email Address
F. Signature
Your signature certifies that all information provided above is current and accurate to the best of your knowledge.
Signature
Print Full Name
Job Title
Date
(mm/dd/yyyy)
04/2016
checklist.doc •
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