PWS CERTIFICATION OF NOTIFICATION OF LEAD AND COPPER TAP SAMPLE
RESULTS
INSTRUCTIONS: This form shall be completed and submitted by community or non-transient non-community water systems that take
lead and copper tap samples in accordance with 40 CFR 141.86 (2009). Such systems shall, no later than 30 days after receiving each
individual sample, provide notice of the individual tap results to the persons served by the water system at the specific sampling site(s)
from which the sample(s) were taken, as required by 40 CFR 141.85(d) (2009). NO LATER THAN THREE MONTHS
FOLLOWING THE END OF THE MONITORING, such systems shall also mail a sample copy of the consumers notification of tap
results with this form, completed, to the appropriate Department of Environmental Protection District Office or Approved County
Health Department. For systems that are on a reduced lead and copper monitoring period, the end of the lead and copper monitoring
period is September 30
th
of the calendar year in which the sampling occurred. All information provided on this form shall be typed or
printed in ink.
I. General Information
:
Public Water System (PWS) Name
:PWS Identification Number
PWS Type: Community Non-Transient Non-Community
PWS Size: Small
Contact Person's Mailing Address
:
e:
:
:
Contact Person's Telephone Number
:
Contact Person's Fax Number
Contact Person's E-Mail Address
:
Date of the end of the Lead and Copper Monitoring Period
:
II. Certification*
A. Certification by a Community Water System (CWS)
The CWS identified in Part I of this form had one or more lead and copper tap sample results for lead or for copper during the
following monitoring period:
I am duly authorized to sign this form on behalf of the CWS. I certify that, no later than 30 days after the CWS received each
individual lead and copper tap sample result during this monitoring period, the CWS notified each customer by mail, as required by
40 CFR 141.85(d) of the sample result.
Signature and Date Printed or Typed Name Title
B. Certification by a Non-Transient Non-Community Water System (or a Community Water System Serving a Facility Where the
Population Served Is Prevented from Making Plumbing Improvements and Is Not Separately Charged for Water Consumption)
The PWS identified in Part I of this form had one or more lead and copper tap sample results for lead or for copper during the
following monitoring period:
I am duly authorized to sign this form on behalf of the PWS. I certify that, no later than 30 days after the PWS received each
individual lead and copper tap sample result during this monitoring period, the PWS provided notice to consumers at sample taps
tested, as required by 40 CFR 141.85(d). If the system posted the sample results in a public place or common area in the
building(s) where the samples were taken, then check the box below.
The PWS posted the sample results in a public place or common area in the building(s) where the samples were taken, as required
by 40 CFR 141.85(d).
Signature and Date Printed or Typed Name Title
* A community water system (CWS) shall complete the certification in Part II.A of this form unless the CWS is serving a facility (such
as a prison or hospital) where the population served is prevented from making plumbing improvements and is not separately
charged for water consumption, in which case the CWS may use the certification in Part II.B of this form. A non-transient non-
community water system shall complete the certification in Part II.B of this form.
Page 1 DEP Form 62-555.900(16)
Incorporated in 62-550.800(4), F.A.C.
Effective Date: October 1, 2010
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