Lead Sampling of Drinking Water in CA Schools
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Lead Sampling of Drinking Water in CA Schools Lead Sampling Plan
Water System Name: ______Water System Number:______School Name:______School Address:______Meeting Date:______
Water System Representative/Designee: School Representative/Designee:
______Signature & Date Signature & Date
______Print Name Print Name
1 | P a g e Sample Recordkeeping Form
Sample No. 1 Name of Building:______Location Description:______Type of Outlet:______Sample I.D.:______Each Sample I.D. should use the following format:
Must match the code generated by the School Lead Reporting tool (https://drinc.ca.gov/lsics/).
(circle sample type): Initial 1st Follow-up 2nd Follow-up Post-corrective action Date & Time Last Used:______Date Sample Collected:______Time Sample Collected:______Name of Sample Collector:______(circle collector type): Water System Operator Water System Representative Lead Concentration (ppb):______NOTES: Sample Recordkeeping Form
Sample No. 2 Name of Building:______Location Description:______Type of Outlet:______Sample I.D.:______Each Sample I.D. should use the following format:
Must match the code generated by the School Lead Reporting tool (https://drinc.ca.gov/lsics/).
(circle sample type) Initial 1st Follow-up 2nd Follow-up Post-corrective action Date & Time Last Used:______Date Sample Collected:______Time Sample Collected:______Name of Sample Collector:______(circle collector type) Water System Operator Water System Representative Lead Concentration (ppb):______NOTES:
3 | P a g e Sample Recordkeeping Form
Sample No. 3 Name of Building:______Location Description:______Type of Outlet:______Sample I.D.:______Each Sample I.D. should use the following format:
Must match the code generated by the School Lead Reporting tool (https://drinc.ca.gov/lsics/).
(circle sample type) Initial 1st Follow-up 2nd Follow-up Post-corrective action Date & Time Last Used:______Date Sample Collected:______Time Sample Collected:______Name of Sample Collector:______(circle collector type) Water System Operator Water System Representative Contractor Lead Concentration (ppb):______NOTES: Sample Recordkeeping Form
Sample No. 4 Name of Building:______Location Description:______Type of Outlet:______Sample I.D.:______Each Sample I.D. should use the following format:
Must match the code generated by the School Lead Reporting tool (https://drinc.ca.gov/lsics/).
(circle sample type) Initial 1st Follow-up 2nd Follow-up Post-corrective action Date & Time Last Used:______Date Sample Collected:______Time Sample Collected:______Name of Sample Collector:______(circle collector type) Water System Operator Water System Representative Contractor Lead Concentration (ppb):______NOTES:
5 | P a g e Sample Recordkeeping Form
Sample No. 5 Name of Building:______Location Description:______Type of Outlet:______Sample I.D.:______Each Sample I.D. should use the following format:
Must match the code generated by the School Lead Reporting tool (https://drinc.ca.gov/lsics/).
(circle sample type) Initial 1st Follow-up 2nd Follow-up Post-corrective action Date & Time Last Used:______Date Sample Collected:______Time Sample Collected:______Name of Sample Collector:______(circle collector type) Water System Operator Water System Representative Contractor Lead Concentration (ppb):______NOTES: Sample Recordkeeping Form
Sample No. ___ Name of Building:______Location Description:______Type of Outlet:______Sample I.D.:______Each Sample I.D. should use the following format:
Must match the code generated by the School Lead Reporting tool (https://drinc.ca.gov/lsics/).
(circle sample type) Initial 1st Follow-up 2nd Follow-up Post-corrective action Date & Time Last Used:______Date Sample Collected:______Time Sample Collected:______Name of Sample Collector:______(circle collector type) Water System Operator Water System Representative Contractor Lead Concentration (ppb):______NOTES:
7 | P a g e Sample Location Map