Number of People Served:



Water System Name: Click here to enter text. PWSID: Click here to enter text.Contact Person: Click here to enter text. Title: Click here to enter text. Date Certified: Click here to enter text.?CWS ?NTNCWS Number of People Served: ? Less than 100? 101 to 500? 501 to 3,300? 3,301 to 10,000? 10,001 to 100,000? More than 100,000Signature:Results of monitoring # of samples required # of samples submitted 90th Percentile Pb (ppm) 90th Percentile Cu (ppm)_ If the State has informed you that it will calculate your 90th percentile levels, you do not need to submit the 90th percentile calculations. However, you must still provide your sample results to the State by the deadline that they have specified. Water quality parameter sample results, if required, must be attached to this form. # of WQP tap samples required # of WQP tap samples submitted # of entry point samples required # of entry point samples submitted Change in Sampling SiteOriginal site Street Address: Click here to enter text.City or Town: Click here to enter text.Targeting Criteria Tier: ?1 ?2 ? 3New site Street Address: Click here to enter text.City or Town: Click here to enter text.Targeting Criteria Tier: ?1 ?2 ? 3Distance between sites (approximate): Click here to enter text.Reason for change (attach additional pages if necessary) ................
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