Lead Testing in Child Care Facilities Application Form

Step 1 of the Application Process for Child Care Facilities LS-002

Facility Name*
Address*
Street Address Address Line 2 City ZIP / Postal Code
Facility Coordinator*
First Last
Program's Point of Contact
Facility Coordinator Phone #*
Facility Coordinator Cell Phone #*
Facility Coordinator Email*
What is the age range for all attendees?*
Original facility construction date*

If unknown, type "unknown"
Where does your drinking water come from?*
- Public Water Supply
- Private Well
Has your facility tested for lead in drinking water in the past?*
- Yes
- No
If yes, when:
What percentage of students are in the Free & Reduced Lunch Program?*
What is the clieneles' median household income?*
What is the combined number of children and staff in the facility?*
What is the number of proposed sample locations?*
Lead Sampling Coordinator Name*
First Last
Individual who will be mailed supplies and conduct sampling
Lead Sampling Coordinator Job Title*
Lead Sampling Coordinator Mailing Address
Street Address Address Line 2 City ZIP / Postal Code

Address used to send sampling supplies
Lead Sampling Coordinator Telephone #*
Lead Sampling Coordinator Cell Phone #*
Lead Sampling Coordinator Email*
Do you wish for your facility to be recognized for participating in the DEQ's Certified Lead Free Drinking Water Award Program?*
- Yes
- No
Consent*
I hereby acknowledge that I have read, understand, and agree to implement the EPA's 3Ts guidance document for establishing a Lead Testing Program.