Form EQP6786 "Preliminary Distribution System Materials Inventory (Dsmi) Reporting Form" - Michigan

What Is Form EQP6786?

This is a legal form that was released by the Michigan Department of Environment, Great Lakes, and Energy - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2019;
  • The latest edition provided by the Michigan Department of Environment, Great Lakes, and Energy;
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  • Fill out the form in our online filing application.

Download a fillable version of Form EQP6786 by clicking the link below or browse more documents and templates provided by the Michigan Department of Environment, Great Lakes, and Energy.

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Download Form EQP6786 "Preliminary Distribution System Materials Inventory (Dsmi) Reporting Form" - Michigan

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MICHIGAN DEPARTMENT OF ENVIRONMENT, GREAT LAKES, AND ENERGY
DRINKING WATER AND ENVIRONMENTAL HEALTH DIVISION
P
D
S
M
I
RELIMINARY
ISTRIBUTION
YSTEM
ATERIALS
NVENTORY
Issued under authority of the Safe Drinking Act, 1976 PA 399, and Administrative Rules, as amended. Administrative Rule R 325.10604(c)(i)
requires a water supply to complete and submit a preliminary distribution system materials inventory to the
Michigan Department of Environment, Great Lakes, and Energy (EGLE) by January 1, 2020.
Supply Name
WSSN
Population Served
Number of Service Connections
County
The primary focus of the preliminary Distribution System Materials Inventory (DSMI) is to identify lead service lines,
galvanized steel previously connected to lead, or service lines of unknown material. This inventory will estimate the
number of high-risk service lines and describe the reliability of existing records, thereby providing important information for
planning service line verification and replacement efforts. The complete DSMI, which is due in 2025, will require
characterization of all service line materials (lead, galvanized, copper, and plastic). Instructions for completing this form
are provided at the end of the document.
1. Does this water supply have service lines meeting the following definition?
“Service line” means the pipe from the discharge of the corporation fitting to customer site piping or to the building
plumbing at the first shut-off valve inside the building, or 18 inches inside the building, whichever is shorter.
Note: For the purposes of this inventory, Manufactured Housing Community (MHC) connections to units (risers)
are considered service lines, so MHCs should fill out this entire form.
YES. If yes, complete this form in its entirety.
NO. If no, skip to Questions 7 and 8 and the Certification.
2. Complete the table below.
Estimated Number of Service Connections by Service Line Material
A service line includes any section of pipe from the water main to the building plumbing at the first shut-off valve inside the
building, or 18 inches inside the building, whichever is shorter.
Contains neither
Unknown
Contains
Lead nor
Any Portion
Galvanized
Galvanized
Contains
Previously
Total**
Previously
Likely
Likely Does
Lead
Connected to
Material(s)
Connected to
Contains
Not Contain
Lead*
Unknown
Lead
Lead
Lead
*If a galvanized line is still connected to lead, it is a lead service line and must be counted in the first column.
**The total number should equal the total number of potable water service lines in your water supply (residential, commercial,
industrial, other).
3. Describe the sources of information used to summarize or estimate the data above (see instructions for a list
of potential sources of information).
EGLE Environmental Assistance Center
Michigan.gov/EGLE
EQP6786
Telephone:1-800-662-9278
Page 1 of 4
Rev. 7/2019
MICHIGAN DEPARTMENT OF ENVIRONMENT, GREAT LAKES, AND ENERGY
DRINKING WATER AND ENVIRONMENTAL HEALTH DIVISION
P
D
S
M
I
RELIMINARY
ISTRIBUTION
YSTEM
ATERIALS
NVENTORY
Issued under authority of the Safe Drinking Act, 1976 PA 399, and Administrative Rules, as amended. Administrative Rule R 325.10604(c)(i)
requires a water supply to complete and submit a preliminary distribution system materials inventory to the
Michigan Department of Environment, Great Lakes, and Energy (EGLE) by January 1, 2020.
Supply Name
WSSN
Population Served
Number of Service Connections
County
The primary focus of the preliminary Distribution System Materials Inventory (DSMI) is to identify lead service lines,
galvanized steel previously connected to lead, or service lines of unknown material. This inventory will estimate the
number of high-risk service lines and describe the reliability of existing records, thereby providing important information for
planning service line verification and replacement efforts. The complete DSMI, which is due in 2025, will require
characterization of all service line materials (lead, galvanized, copper, and plastic). Instructions for completing this form
are provided at the end of the document.
1. Does this water supply have service lines meeting the following definition?
“Service line” means the pipe from the discharge of the corporation fitting to customer site piping or to the building
plumbing at the first shut-off valve inside the building, or 18 inches inside the building, whichever is shorter.
Note: For the purposes of this inventory, Manufactured Housing Community (MHC) connections to units (risers)
are considered service lines, so MHCs should fill out this entire form.
YES. If yes, complete this form in its entirety.
NO. If no, skip to Questions 7 and 8 and the Certification.
2. Complete the table below.
Estimated Number of Service Connections by Service Line Material
A service line includes any section of pipe from the water main to the building plumbing at the first shut-off valve inside the
building, or 18 inches inside the building, whichever is shorter.
Contains neither
Unknown
Contains
Lead nor
Any Portion
Galvanized
Galvanized
Contains
Previously
Total**
Previously
Likely
Likely Does
Lead
Connected to
Material(s)
Connected to
Contains
Not Contain
Lead*
Unknown
Lead
Lead
Lead
*If a galvanized line is still connected to lead, it is a lead service line and must be counted in the first column.
**The total number should equal the total number of potable water service lines in your water supply (residential, commercial,
industrial, other).
3. Describe the sources of information used to summarize or estimate the data above (see instructions for a list
of potential sources of information).
EGLE Environmental Assistance Center
Michigan.gov/EGLE
EQP6786
Telephone:1-800-662-9278
Page 1 of 4
Rev. 7/2019
P
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NVENTORY
EQP6786
4. Describe your level of confidence in the sources of information discussed in Question 3.
Very confident
Somewhat confident
Not very confident
Not confident
Describe:
5. How common is it to find discrepancies in your service line data (for example, services you expected to be
lead turned out to be copper)?
Frequently
Occasionally
Seldom
Never
Not Enough Information
Describe, including any common patterns:
6. In general, describe the composition of lead services lines identified in the column titled “Any Portion
Contains Lead.” For example, are services primarily full lead lines, partial lead lines (main to curb stop, curb
stop to water meter), or lead goosenecks?
7. What other information can you share about your preliminary DSMI?
8. Beyond your service lines, do other documents previously submitted to EGLE (including the General Plan,
Reliability Study, issued permits, and/or Asset Management Plan) in combination properly characterize the
remainder of your current distribution system?
YES, my general plan, reliability study, issued permits, and/or asset management plan characterize the rest
of my current distribution system.
NO. If no, please contact your district engineer to update your documentation.
Certification of Preliminary Distribution System Materials Inventory
I certify that I have reviewed available documentation related to the materials in this water supply’s distribution system,
and the information herein is accurate and complete to the best of my knowledge and information.
Signature
Date
Print Name
Title
When complete, submit this signed form to your EGLE district office no later than January 1, 2020.
Page 2 of 4
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PRELIMINARY DISTRIBUTION SYSTEM MATERIALS INVENTORY (DSMI)
REPORTING FORM INSTRUCTIONS
Water supplies should review all records documenting the materials used to construct and repair service lines and use
that information to complete this reporting form.
Potential sources of service line information may include, but are not limited to, the following:
Plumbing codes
Operation and maintenance manuals
Plumbing permits
Permit files
Distribution maps and drawings
As-built drawings
Tap records
Existing water quality data
Inspection and maintenance records
Property tax records
Meter installation records
Interviews with senior personnel, building
inspectors, and retirees
Billing records
Community survey
Water asset databases
Other
Geographic Information System
Standard operating procedures
Complete the Service Line Materials Table
The service line materials table summarizes potable water service connections by broad material categories, focusing on
service lines containing lead, galvanized steel previously connected to lead, or service lines of unknown material. A
service line includes any section of pipe from the water main to the first shut-off valve inside the building or up to
18 inches inside the building, whichever is shorter. The number of service lines in each of the following categories need to
be reported:
Any Portion Contains Lead: Any portion of a service line that is made of lead or any lead pigtail, lead
gooseneck, or other lead fitting that is connected to the service line, or both. In short, any service line that
contains any lead.
Galvanized Previously Connected to Lead: A galvanized service line that WAS previously connected
to a lead service line, gooseneck, or pigtail. If a galvanized line is still connected to lead, it is considered a
lead service line and must be counted in the category above.
Unknown: While a water supply may not be certain of the materials content of some service lines, they
may have information that indicates the likelihood of a service line containing lead. For planning
purposes, it is helpful to record this information. Therefore, three categories of unknown service lines are
provided.
Unknown - Likely Contains Lead: While not known for certain, service lines the water supply
o
believes are likely to contain lead.
Unknown - Likely Does NOT Contain Lead: While not known for certain, service lines the
o
water supply believes are NOT likely to contain lead.
Unknown – Material(s) Unknown: Service line materials are fully unknown. Supply has no
o
information regarding the likelihood of lead being present in the service line.
Contains neither Lead nor Galvanized Previously Connected to Lead: Service lines that are known
to contain NO lead in any portion. These typically include copper, plastic, cast iron, ductile iron, or
galvanized that was NEVER connected to lead. If a galvanized service line was previously connected to
lead, it should not be included in this category, but rather included with the second bullet above.
All physically connected potable water services must be included in this table even if there is no current active account.
Complete the table to the best of your ability based on your available records and/or knowledge of the system. If you do
not know the answer, use the unknown category. You will not be penalized for acknowledging you do not know. The
purpose of this preliminary inventory is to understand current service line materials documentation and knowledge. The
total number of service lines in the lower right-hand box should equal the total number of service lines in your system.
Page 3 of 4
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Answer Supporting Questions
Provide answers to the questions asked. Because water supplies differ significantly in terms of service line materials and
records, many questions require a narrative response to allow flexibility. Please provide thorough answers that provide
meaningful information about the status of your water supply’s service line inventory.
Submit Form to the Michigan Department of Environment, Great Lakes, and Energy (EGLE)
Submit the completed and signed reporting form to the appropriate EGLE district office no later than January 1, 2020. See
below for district office mailing and email addresses.
EGLE District office locations and email addresses:
CADILLAC DISTRICT OFFICE
LANSING DISTRICT OFFICE
120 West Chapin Street
525 West Allegan
Cadillac, Michigan 49601-2158
(Constitution Hall, 1st Floor, South)
Fax: 231-775-4050
P.O. Box 30242
EMAIL:
EGLE-DWEH-Cadillac@Michigan.gov
Lansing, Michigan 48909-7742
Fax: 517-241-3571
GRAND RAPIDS DISTRICT OFFICE
EMAIL:
EGLE-DWEH-Lansing@Michigan.gov
State Office Building
5th Floor 350 Ottawa Avenue NW, Unit 10
BAY CITY DISTRICT OFFICE
Grand Rapids, Michigan 49503-2341
401 Ketchum Street, Suite B
Fax: 616-356-0202
Bay City, Michigan 48708
EMAIL:
EGLE-DWEH-Grand-Rapids@Michigan.gov
Fax: 989-891-9237
EMAIL:
EGLE-DWEH-Bay-City@Michigan.gov
JACKSON DISTRICT OFFICE
301 East Louis Glick Hwy
WARREN DISTRICT OFFICE
Jackson, Michigan 49201-1556
27700 Donald Court
Fax: 517-780-7855
Warren, Michigan 48092-2793
EMAIL:
EGLE-DWEH-Jackson@Michigan.gov
Fax: 586-751-4690
EMAIL:
EGLE-DWEH-Warren@Michigan.gov
KALAMAZOO DISTRICT OFFICE
7953 Adobe Road
MARQUETTE DISTRICT OFFICE
Kalamazoo, Michigan 49009-5025
1504 West Washington Street
Fax: 269-567-3555
Marquette, Michigan 49855
EMAIL:
EGLE-DWEH-Kalamazoo@Michigan.gov
Fax: 906-228-4940
EMAIL:
EGLE-DWEH-Marquette@Michigan.gov
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