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MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH

SUBMETERING OF WATER AND SEWER CERTIFICATION FORM

*In accordance with M.G.L. c. 186, § 22 and 105 CMR 410.000: Minimum Standards of Fitness for Human Habitation

(State Sanitary Code Chapter II), the following dwelling unit is eligible for the imposition on the tenants of a charge for

water and/or sewer service.

PROPERTY INFORMATION

Address:

Unit #

# Of units in bldg.

City/Town:

Zip Code:

EQUIPMENT INSTALLATION INFORMATION

105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the

imposition on tenants of a charge for water and/or sewer. The devices must meet the following specifications:

Showerheads with maximum flow rate not to exceed

gallons per minute (2.5 gpm)

2/10

Faucets with maximum flow rate not to exceed

gallons per minute (2.2 gpm)

6/10

Ultra-low flush water closets (toilets) not to exceed

gallons per flush (1.6 gpf)

The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must

meet the standards of accuracy and testing of the American Water Works Association or similar accredited association.

A licensed plumber must install the water closets and submetering equipment.

Submetering equipment information:

Manufacturer

Model #

Licensed Plumber Certification

Print Name of Plumber

License #

Date

I certify that (check all that apply):

I have installed the submetering equipment listed above in accordance with accepted plumbing standards.

I have installed one or more water closets not exceeding 1.6 gallons per flush.

Determined that existing water closets do not exceed 1.6 gallons per flush.

The plumbing permit issued by the city/town, if required, is attached.

Dwelling unit is connected directly to a meter installed by a water company and, in accordance with

M.G.L . c. 186, § 22(p), does not require the installation of a submeter.

Signed under the pains and penalties of perjury,

Signature of Licensed Plumber

Property Owner Certification

I certify that: (1) This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage

in accordance with the water submetering law (MGL c. 186, §22); (2) All showerheads, faucets, and water closets in this

dwelling unit are water conservation devices that meet the standards specified above; (3) The water submeter measuring

the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards

specified above, or the water meter measuring the use of water in this dwelling unit was installed by a “water company”

as defined in M.G.L. c. 186, § 22; (4) The water meter or submeter measures the water usage exclusive to this unit; (5) I

will provide to the tenants of this dwelling unit, prior to occupancy, a written rental agreement that clearly provides for the

separate charging of water and/or sewer service, and a copy of this certification form; (6) That all information included on

this certification is true and accurate to the best of my knowledge.

Signed under the pains and penalties of perjury,

Print Name of Owner

Signature of Owner

Date

The property has been transferred to owner above and the unit

Received

remains in compliance with the requirements of M.G.L. c. 186, §22

Date:

by BOH:

*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING

MDPH-CSP Submetering Form, Rev 11-4-16

Submetering Of Water And Sewer Certification Form - Massachusetts Department Of Public Health

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