Laserfiche WebLink
• <br /> lif_.al MINNESOTA DEPARTMENT OF HEALTH <br /> M D l Lead/Copper Results Delivery Certification <br /> Municipal System(Population Greater Than 3,300) <br /> PWS Name:Elk River PWSID: 1710004 <br /> Compliance Period: June 1,2016- September 30,2016 <br /> Z9. PLEASE COMPLETE THIS FORM. <br /> Delivery/Notification must be completed within 30 days. <br /> Delivery/Notification: <br /> Residences were notified by U.S.Mail on }, � 24, AP i. (date). You must submit a copy of the letter <br /> that you sent to the residents notifying them of th results,along with this certification form. <br /> Failure to provide notice of the lead/copper results to persons served at the sites that were tested and submit this <br /> Results Delivery Certification form to the MDH will result in enforcement action,which may include fines, <br /> from the U.S.Environmental Protection Agency and/or the MDH. <br /> I certify that lead/copper results were provided to persons served at the sites that were tested along with the <br /> following information: MCLGs,ALs and their definitions,a fact sheet on the health effects of lead/copper <br /> which includes steps to reduce exposure to lead/copper in drinking water, and contact information for the water <br /> utility. I further certify that notification was completed within 30 days after our system learned of the results, <br /> and that if the residence is a rental property,both the occupant(s)and rental property owner were notified. <br /> Signature: Print Name: Et'i c, V [k <br /> Job Title: W ebiel Phone: Date: /►c. <br /> Email Address: -C;i/.tic �? � k(t`uEe,�i} r1► .C <br /> Please print clearly <br /> Mailing Address: <br /> � c on f64uu dad a copy of Minnesota Department of Health <br /> restdent of fic on letter to in clos d c o Pauline Wuoti,Compliance Officer <br /> 1 envelope,within 10 des a cation hsps Community Public Water Supply Unit <br /> campletod. � , <br /> Environmental Health Division <br /> P.O.Box 64975 <br /> St.Paul,Minnesota 55164-0975 <br /> If you have any questions,please call 651/201-4674,or email pauline.wuoti@state.mn.us. <br /> 03/10 <br /> 88 <br />