checklist.doc • Page 2 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
facility taken lead & copper sample(s) in the last 12 months?
YES NO
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
plumbing lines and equipment with the type of material noted.)
YES NO
Has your school or facility prepared a sampling plan showing all fixtures, their ID
numbers, and the last date they were sampled for lead or copper?
YES NO
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
for students?
YES NO
If yes, are students required to bring bottled water with them to your
school or facility?
YES NO
Does your school or facility use bottled water as your main source of drinking water
for staff?
YES NO
Does your school or facility use bottled water as your main source of drinking water
for visitors?
YES NO
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
3Ts Toolkit.
YES NO
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
PWS main line in the street outside your facility into your facility.
YES NO
Describe your current school/facility lead & copper in drinking water program. Please provide a short description in
the box provided and attach a copy.
