Home Sampling For Lead And Copper
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1
2Massachusetts Department of Environmental Protection - Drinking Water Program
LCR
Chain of Custody (COC)
COC
Home Sampling for Lead and Copper (COM Systems Only*)
TO BE COMPLETED BY RESIDENT FOR HOME SAMPLING:
Address: ____________________________________Town______________________________
Name: __________________________________ Phone No _______________________ (Optional)
E-Mail __________________________________ (optional)
Were there any recent changes to your home plumbing?
Yes ________ No ________
Describe the changes, including the date they were made: _______________________________________
______________________________________________________________________________________
Do you have a treatment system or home filter? |Yes: ___ (POU) ___ POE___|
No ___
Point of Use treatment Device (POU) /Point of Entry treatment Device (POE)
Indicate Location of Sample Collected for Lead & Copper Testing:
Please read the attached instructions. Collect cold water only from Kitchen Faucet (or Bathroom Faucet) where you would
normally use the water to drink or prepare food. The water must stay stagnant (not used in the house) for at least 6 hours.
Sample location:
Kitchen ______ Bathroom _______
Sample was taken:
Time ________ Date ________
Water was last used before sample was taken:
Time ________ Date ________
I have read the attached Home Sample Collection Instructions and have taken a tap sample in accordance with these
procedures:
Yes ________ No ________
__________________________________
____/____/____
Resident’s Signature
Date
============================================================================
TO BE COMPLETED BY PWS COLLECTOR AFTER VERIFYING THAT THE SAMPLE WAS COLLECTED
CORRECTLY AND THAT THE COC WAS PROPERLY COMPLETED:
Sample accepted: _____
Sample rejected: _____ (check applicable reason)
_____ Collected at wrong location
_____ COC is not filled out properly
_____ Improper standing time
Note: If the sample is rejected, the collector shall indicate the reason on the COC and provide a copy to the
homeowner/resident. The collector must discard the sample and provide a new sample kit to the homeowner/resident
within one week.
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.
___________________________
__________________________
____/____/____
PWS Collector’s Signature
Print Name
Date
============================================================================
PWS Filing Requirement
PWS must staple this completed form to the certified laboratory chain of custody form for this sample and keep copies of
both documents in accordance with 310 CMR 22.00 record keeping requirements.
* Non-transient non-community systems (NTNC) are required to use their certified laboratory chain of custody form.
6/27/2016
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