Department of Environmental Protection – Bureau of Water System Engineering

401 East State Street – P.O. Box #420 – Mail Code 401-04Q

Trenton, New Jersey 08625-04201

Materials Evaluation Survey

*For Non-Community Water Systems*

Pursuant to 40 CFR 141.86(a), each water system shall complete a materials evaluation of its distribution system in order to identify a pool of targeted sampling sites. After completion of this form, complete the Lead and Copper Sample Site Certification form (BWSE-15) for each site sampled in the last round of sampling.

1. Water System Name: ____________________________________________ 2. PWSID #: ______________________

3. Water System Owner: ___________________________________________________________________________

Phone Number: _____________________________ Email Address: _________________________________________

4. Water System Operator (if applicable): _______________________________________________________________

Phone Number: _____________________________ Email Address: _________________________________________

5. Population Served: ____________________________

6. Date Form Completed: ____________________________________

MATERIALS EVALUATION

When was the original building constructed?	Date:
Were any buildings or additions added to the original facility?	Yes ☐ No ☐
If yes, provide the date(s) of construction and locational name(s) of the additions. Insert additional rows as needed.	Date: Location/Building:
	Date: Location/Building:
	Date: Location/Building:
If the building was built or repaired since 1986 was lead free plumbing and solder used? *Per the 1986 amendment to the Safe Drinking Water Act “lead free” was defined as solder and flux with no more than 0.2% lead and pipes with no more than 8%. An amendment effective in January 2014 now establishes the definition for “lead free” as a weighted average of 0.25% lead calculated across the wetted surfaces of a pipe, pipe fitting, plumbing fitting, and fixture and 0.2% lead for solder and flux.	Yes ☐ If no, Location/Building(s):	No ☐
Where are the most recent plumbing repairs and replacements? *Note that these areas may no longer meet the Tier criteria for lead and copper sampling	Location/Building: Description:
	Location/Building: Description:
	Location/Building: Description:
What material is the service connection from the well(s) to the building(s) made of? *If multiple service connections exist, provide information for all service connections. Insert additional rows as needed.	Location/Building: Material:
	Location/Building: Material:
	Location/Building: Material:
Is point of entry (POE) or point of use treatment being used?	Yes ☐	No ☐
If yes, provide the type and location	Type(s): Location(s):
Specifically, what are the potable water pipes made of in your facility? (Locations should be noted) · Lead · Plastic · Copper · Galvanized metal · Cast Iron · Other	Material: Locations:
Was lead solder used in your facility? If yes, document the location.	Yes ☐ Location:	No ☐
Are brass fittings, faucets or valves used in your drinking water system? (Note: most faucets are brass on the inside)	Yes ☐	No ☐
Do the plumbing materials in your facility contain plastic pipes which contain lead plasticizers?	Yes ☐	No ☐
Do you have storage tanks as part of your distribution system? If so, what material are these tanks made of?	Yes ☐ Material:	No ☐
Identify areas of oldest water age in the building based on direction of water flow and note them including the following: · Dead ends · Low use areas	Location: Justification:
	Location: Justification:
	Location: Justification:
How many of the following outlets provide water for consumption? *Note that per CFR141.86(b)(2) first-draw samples from a nonresidential building shall be collected at an interior tap from which water is typically drawn for consumption. Restroom sinks may only be used if the facility does not have enough of the previously identified appropriate locations to sample from.	Water Coolers _______ Bubblers _________ Kitchen Taps ________ Ice Makers _________ Drinking Fountains _________ Other Drinking Water Outlets ________
Are any of the water fountains on EPA’s recall list? https://nepis.epa.gov/Exe/ZyPDF.cgi?Dockey=30005UPU.txt	Yes ☐	No ☐
Do outlets that provide drinking water have accessible screens or aerators? (Standard faucets usually have screens. Many coolers and bubblers also have screens.) If no, note the locations.	Yes ☐ Locations:	No ☐
Does the facility have a screen or aerator maintenance program? If yes, attach copy of written maintenance plan. If yes, who is responsible for the program?	Yes ☐ Responsible entity:	No ☐
Does the facility have a filter maintenance and operation program? If yes, attach copy of written maintenance plan. If yes, who is responsible for the program?	Yes ☐ Responsible entity:	No ☐
Are there signs of corrosion, such as frequent leaks or rust-colored water? If yes, note the locations.	Yes ☐ Locations:	No ☐
Have there been any complaints about bad (metallic) taste? If yes, note the locations.	Yes ☐ Locations:	No ☐
Is any electrical equipment grounded to water pipes? If yes, note the locations.	Yes ☐ Locations:	No ☐
Check building files to determine whether any initial WQP water samples (for compliance or non-compliance purposes) have been taken from your building. If yes, complete WQP specific information as applicable. Attach additional sheets with additional data, as needed. Continued on next page	Yes ☐ No ☐
	pH Sample Date: Result: Sample Location:
	Temperature Sample Date: Result: Sample Location
	Conductivity Sample Date: Result: Sample Location
	Calcium Sample Date: Result: Sample Location
	Total Alkalinity Sample Date: Result: Sample Location
	Orthophosphate Sample Date: Result: Sample Location
	Silica Sample Date: Result: Sample Location
Are blueprints of the building available?	Yes ☐	No ☐
Are renovations being planned for part or all of the plumbing system? If yes, provide details.	Yes ☐ No ☐
	Location: Description:
	Location: Description:
	Location: Description:
Is a schematic of the water system included which identifies drinking water outlet locations, building age and plumbing materials? A schematic is required to be submitted with this form.	Yes ☐	No ☐

I have verified and certify the information listed in this form is true and accurate to the best of my knowledge and belief:

Owner/Executive Director Signature: __________________________________________ Date: _____________________

Printed Name: ____________________________________________________ Title: _____________________________

Licensed Operator Signature: _______________________________________________ Date: _____________________

Printed Name: ____________________________________________________ License Number: ____________________