Work Notice Form printable pdf download

Attention Public Water Systems: Please adapt this form for your own use. An electronic copy of this form is located at the

MassDEP website at

LEAD SERVICE LINE REPLACEMENT PROGRAM

City/Town: _______________________

PWS Name: _______________________

PWS ID#: ________________________

WORK NOTICE FORM

Second Notice Date:____________

ADDRESS:______________________________________________________________

NAME:___________________________ PHONE No.___________________________

Dear Homeowner/resident:

Paragraph 1. Why are you doing this? Did the system fail the lead action level, If so when. Or is the system

doing this as part of routine maintenance? Use the paragraph that is applicable to your situation

On ____________the _________water system exceeded the 0.015ppm action level for lead. As a result we

are required to identify and replace annually at least seven percent of all identified lead service lines until the

system complies with the lead action level for two consecutive monitoring periods. OR

As part of a program to replace services (the pipe which connects your house to the water main in the street)

that are made of lead with new copper piping, we will be working on your street on or about DATE.

We have previously sent you a Notice regarding the Town’s Lead Service Line Sampling program. You

either did not respond, or indicated that “you did not want to replace the portion of the lead service that

you own”. This notice provides a second chance to reconsider the lead service line replacement for the

portion that you own.

While the water from our drinking water source(s) contains no lead and the water in our local pipes has no

lead, if the water is left stagnant for 6 or more hours in contact with plumbing materials in your home, which

may contain lead, it can leach out the lead into the water. This leaching is due to the water coming into

contact with your pipes and fixtures that contain lead. Lead is of greatest risk to young children and pregnant

women and can slow down normal mental and physical development. While most lead exposure comes from

lead paint and lead dust in soil, we are concerned about any lead that can leach into your water. PWS NAME

provides treatment to reduce lead corrosivity, but some homes may still have higher levels.

We are replacing the service line because it has been identified as being made of lead. Lead pipe, copper

pipe joined with lead solder, and certain types of brass can leach lead into your drinking water when the

water sits stagnant. Replacement of the service pipe will reduce that chance that water which sits stagnant in

the service line will leach enough lead to be of health concern. Of course, if your home has any other lead

containing plumbing, there could still be opportunities for lead to leach into the water. This can include

certain brass faucets and the solder joining copper pipe if it was installed prior to the lead solder ban in 1986.

The simple way to ensure that your water has no lead is to let it run until it is very cold before using it. See

prior comment

The PWS NAME owns and controls a portion of your lead service pipe from our water main in the street to

the shutoff valve located in the sidewalk. You own the remainder of the line, from the shut-off valve on

the sidewalk into your basement. We will be replacing our portion of the line. This will involve an

Work Notice Form