Drinking Water Program
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2LCR- Consecutive systems
MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION
DRINKING WATER PROGRAM
LEAD & COPPER RULE-CONSECUTIVE SYSTEMS SAMPLING REDUCTION REQUEST
(With attached Roles and responsibilities Chart)
Instructions: The selling (parent) and purchasing (consecutive) systems must complete Sections A and B of this form and
the Roles and Responsibility Chart on page 2 and return them to the DEP with a completed copy of the DEP sampling
plan form (LCR-A) by the date noted below. A reduction request must be completed for each individual purchasing
(consecutive) system.
SECTION A. TO BE COMPLETED BY PURCHASING (CONSECUTIVE) PUBLIC WATER SYSTEM
CITY/TOWN: _____________________________________________________ PWS ID #: ___________________
PUBLIC WATER SYSTEM NAME: _______________________________________________________________
ADDRESS: _____________________________________________________________________________________
TELEPHONE (
)__________________ FAX: (
)______________ EMAIL: ________________________
THE __________________________________________________ (insert PWS name) requests:
_____ A reduction in the lead and copper tap monitoring requirements;
_____ An exemption from the water quality monitoring requirements;
and attests that all the following conditions are met:
a.
We purchase water from the _____________________which has control of the source water and its treatment;
b. We do not treat the water in any way (e.g. treatment includes chlorination, adding sequestering agent, etc);
c.
We do not mix our purchased supply with other sources.
I certify under penalty of law that I am the person authorized to fill out this form and the information contained herein is true, accurate
and complete to the best of my knowledge and belief.
_______________________________________________________________________________________________
Signature of Purchasing (Consecutive) Water Supplier
Date
________________________________________________________________________________________________
Type or Print Name
Title
SECTION B. TO BE COMPLETED BY SELLING PUBLIC WATER SYSTEM
CITY/TOWN: _______________________________________________________ PWS ID #: ________________________
PUBLIC WATER SYSTEM NAME: _______________________________________________________________
ADDRESS: _____________________________________________________________________________________
TELEPHONE (
) __________________ FAX: (
)______________ EMAIL: ________________________
______ (check (√) WE SELL WATER TO THE ABOVE PUBLIC WATER SYSTEM
I certify under penalty of law that I am the person authorized to fill out this form and the information contained herein is true,
accurate and complete to the best of my knowledge and belief.
____________________________________________________________________________________________
Signature of Selling Water Supplier
Date
_____________________________________________________________________________________________
Type or Print Name
Title
to:
Department of Environmental Protection, Drinking Water Program
Please return this form by _________
_____________________________________________________
Attention: ____________________________________________
DEP USE ONLY: APPROVED: ________ DISAPPROVED: _________OTHER_______________________________
DWP REVIEW STAFF: _____________________ Signature: _______________________________ Date: ___/____/____
DATE SUBMITTED TO EPA: ______________ STATUS AND DATE OF EPA REVIEW: ______________________
Page 1 of 2
10/6/2004
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