Dutchess County, NY · Dutchess County
Sample Site Identification and Certification
This sample form helps public water systems identify lead sampling sites and certify how lead and copper samples were collected.
At a glance
- Issued by
- City of Dutchess County · Dutchess County, Dutchess County, New York
- Notarization
- Not required: file this form without a notary.
- Official source
- dutchessny.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
Public water systems can use this form to document sampling sites and certify lead and copper sample collection methods. It asks for system details, counts and categories of sites, sources explored to identify lead pipes and service lines, explanations of certain site counts, and a signed certification. The form also refers to enclosing materials distributed to residents and homeowner certification forms.
Who needs it
Public water system representatives who are documenting lead sampling sites and certifying the collection methods used for samples.
How to submit it
Submit it to the county department named on the form; check the county website for current contact details.
About notarization
This document is signed without a notary; it also calls for resident collection-method materials and homeowner certification forms, with no notarial step stated.
How to submit this form
- 1
Download the Form
Download the Sample Site Identification and Certification PDF.
- 2
Complete the System Details
Fill in the water system name, type, address, size, telephone number, system ID, and contact person.
- 3
Document Sites and Methods
Record site counts, sources explored, any requested explanations, and the sample collection certifications.
- 4
Gather Referenced Materials
Include the resident collection-method materials and homeowner certification forms referenced in the document.
- 5
Sign and Submit
Sign and date the certification, then submit it to the county department named on the form.
Frequently asked questions
- Do I need a notary for the Sample Site Identification and Certification?
- No. The form has a signature and date line but no notary block; it also refers to resident collection-method materials and homeowner certification forms without stating a notarial step.
- How do I submit the Sample Site Identification and Certification?
- The document does not provide submission instructions. Submit it to the county department named on the form; check the county website for current contact details.
- What information does the form request?
- It requests water system details, counts and categories of sampling sites, sources explored for lead pipes and service lines, explanations of certain counts, and a signed collection-method certification.