8-Exhibit B-Form Lead in Water Clearance Report Template.pdf
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- Attached to
- Environmental Investigation Firms
- Solicitation number
- 550632
- Issued by
- Wayne County, Detroit City, Michigan
About this file
This is an Exhibit B Lead in Water Clearance Report Template developed for the City of Detroit Office of Contracting and Procurement on behalf of the Human, Homeless and Family Services Department as part of an Environmental Services contract. The template provides a standardized form for documenting drinking water sample results collected from residential properties following plumbing component and/or service line replacement work. The report captures visual assessments of replaced plumbing components, verification of proper water sampling collection protocols, and laboratory analysis results measured against the U.S. Environmental Protection Agency action level of 15 parts per billion (ppb) for lead in drinking water. The template includes sections for documenting clearance dates, retesting procedures for samples exceeding EPA action levels, and recommendations for reducing lead exposure through pipe flushing, water filtration, and aerator maintenance.
The clearance report requires certification by a Michigan Certified Lead Inspector or Risk Assessor and mandates submission of original laboratory analysis reports from the Michigan Department of Environment, Great Lakes and Energy Drinking Water Laboratory along with chain of custody forms. The template incorporates appendices for site maps, photographic documentation, and laboratory reports to provide comprehensive evidence of clearance compliance. Reports must be distributed to both the client requesting the clearance and the property owner if different individuals. This standardized reporting format establishes documentation procedures for the three-year grant-funded environmental services contract with the City of Detroit, ensuring consistent evaluation and clearance standards across multiple Detroit locations.
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Text version
Lead Clearance Report
WATER SAMPLE RESULTS
Project/Site Address Address, City, Zip
Occupant Occupant Name
Phone #: ###-###-####
Homeowner Homeowner Name
Homeowner Address, City, Zip
Phone #: ###-###-####
Contractor Contractor Name
Contractor Address, City, Zip
Phone #: ###-###-####
Clearance Date(s) Date Pass/Fail
Contents
Purpose and Clearance Standards for Lead in Drinking Water
General Description of Work Performed (Visual Assessment)
Assessment of Sample Collection
Water Sample Clearance Results
Retesting of Water Samples Above Clearance Levels
Recommendations
Inspector Certification
Appendix A – Site Map
Appendix B – Photos
Appendix C – Laboratory; Original Laboratory Analysis Reports; & Chain of Custody Form
EXHIBIT I
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Purpose and Clearance Standards for Lead in Drinking Water
The purpose of this report is to share drinking water sample results collected from your home after plumbing component and/or service line replacement.
The U.S. Environmental Protection Agency (EPA) action level for lead in drinking water is a result above
15 parts per billion (ppb) or above 0.015 milligrams per liter (mg/L). For clearance, results must be below the EPA action level.
General Description of Work Performed (Visual Assessment)
Date of Visual Assessment: DATE
Location of Plumbing Component
Activity Component Replaced?
NSF/ANSI
61 (or equivalent)
Certified?
Notes
Location Activity Yes/No Yes/No Notes
Location Activity Yes/No Yes/No Notes
Location Activity Yes/No Yes/No Notes
Location Activity Yes/No Yes/No Notes
Assessment of Sample Collection
Clearance water sampling preparation protocol was reported by contractor/homeowner/representative to be performed correctly:
1. All water sampling locations flushed for 5 minutes
2. Aerators removed, cleaned and replaced
3. All water sampling locations flushed for another 5 minutes
4. Water not used for at least 6 hours (stagnation)
Yes/No
Confirmed by:
Contractor/ Homeowner / Rep
Type of service line material verified at clearance Type of material
Was the service line replaced? If so, when?
N/A if copper
DATE
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Water Sample Clearance Results
Date of Water Sample Collection: DATE
Sample Number
Location Lead Concentration in ppb
Does sample exceed EPA action level?
Pass or Fail
# Location Result Yes/No Pass/Fail
BRL = Below Reporting Limits; N/D = Not Detected. “P” samples = first draws; “A” samples = system draws.
Retesting of Water Samples Above Clearance Levels
Date of Water Sample Collection: DATE
Sample Number
Location Lead Concentration in ppb
Does sample exceed EPA action level?
Pass or Fail
# Location Result Yes/No Pass/Fail
BRL = Below Reporting Limits; N/D = Not Detected. “P” samples = first draws; “A” samples = system draws.
Recommendations
Please use the recommendations below to reduce exposure to lead in water:
Flush your pipes before using your water.
If you have not used your water for several hours, flushing your pipes may reduce the amount of soluble (dissolved) lead in your drinking water.
To flush the pipes in your home, do any of the following for at least 5-minutes:
• Turn a faucet on all the way.
• Take a shower.
• Run a load of laundry.
• Run your dishwasher.
After flushing your home’s water, run the water from individual faucets on cold for 1-2 minutes before using the water for drinking or cooking.
Using a filter can reduce lead in drinking water.
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Both particulate and soluble lead can be safely removed from drinking water by using a water filter certified to reduce lead in drinking water. Look for filters that are tested and certified to
NSF/ANSI Standard 53 for lead reduction. Follow the manufacturer’s instructions to install the filter and maintain it. For help choosing a filter, use the EPA guidance tool.
Use cold filtered or flushed water for:
• Drinking, cooking, or rinsing food
• Mixing powdered infant formula
• Brushing your teeth
Do not use hot water for drinking or cooking. Do not cook or drink water from the hot water tap. Lead dissolves more easily into hot water.
Clean your aerator. Aerators (the mesh screens on your sink faucet) can trap pieces of particulate lead. Clean your drinking water faucet aerator at least every 6 months. If there
Be mindful of recent disturbances or repairs to local water supply systems. Local water supply systems include water pipes that carry water to your home. These disturbances may release lead into your water.
Inspector Certification
The information contained in this report is a true and accurate representation of the conditions at this property at the time of lead clearance, based on the professional judgement of the person(s) who conducted and reported this clearance.
Name Date
Michigan Certified Lead Inspector/Risk Assessor # P- 0XXXX
Risk Assessor E-Mail: email address
Note: A copy of this report must be provided to the client requesting the clearance and the property owner if they are different individuals.
https://www.epa.gov/sites/production/files/2018-12/documents/consumer_tool_for_identifying_drinking_water_filters_certified_to_reduce_lead.pdf
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Appendix A – Site Map
A site map of the property is included to identify sample locations as well as justify the number of large volume samples collected (if necessary).
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Appendix B – Photos
Caption Caption
Caption
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Appendix C – Laboratory; Original Laboratory Analysis Reports; & Chain of Custody Form
LABORATORY USED
Michigan Department of Environment, Great Lakes and Energy
Drinking Water Laboratory
3350 N. Martin Luther King Blvd.
P.O. Box 30270
Lansing, MI 48909
P: 517-335-8184
ORIGINAL LABORATORY ANALYSIS REPORTS & CHAIN OF CUSTODY FORM
All original laboratory analysis reports and chain of custody form for any samples that were sent for testing are included in the following pages.
File details come from the government source that posted it. Updated .