BUREAU FOR PUBLIC HEALTH
OFFICE OF LABORATORY SERVICES
PLACE BARCODE HERE
LAB USE ONLY
4710 Chimney Drive, Suite G, Charleston, WV 25302
Telephone (304) 965-2694 Fax (304) 965-2696
► INFORMATION REQUIRED FOR TESTING
►PUBLIC WATER SYSTEM IDENTIFICATION NUMBER:
►PARAMETERS REQUESTED FOR TESTING
PWS ID #:
METALS
►MAIL LABORATORY RESULTS TO
Please call the laboratory for additional tests, a separate bottle may be required.
Business Name:
Contact Name:
Mailing Address:
City/State:
Zip Code:
Telephone:
Fax:
►RESPONSIBLE PARTY FOR BILLING (IF DIFFERENT ):
Business Name:
Contact Name:
Mailing Address:
City/State:
Zip Code:
Telephone:
Fax:
►SAMPLE COLLECTION INFORMATION:
County:
Collection Address:
Collection Point:
Date Collected:
Time:
□ District Engineer.…… District:
□ Sanitarian
Date:
Time:
Sample ID:
□ Sanitary Survey □ Plant Review
□ Lead Assessment □ Customer Request
□ Complaint
□ Other:
►TYPE OF WATER
□ Raw
□ Lab Pure
COMMENTS:
Metals and non-metals are to be collected in separate bottles
LABORATORY USE ONLY
PERSON PREPARING KIT/DATE:
IDENTIFY SAMPLE PRESERVATIVES WHEN SHIPPED:
For: NO3 + NO2 □ H2SO4
►PURPOSE OF SAMPLE:
□ Regulatory Compliance
□ River/Creek
□ *SUVA
NOTE: * These analytes require special sample bottles and preservatives
Lead/Copper Only: Water was last used
►SOURCE OF SAMPLE:
□ Well
NON-METALS
□ *Alkalinity, Total
□ Calcium
□ Calcium Hardness
□ Chloride
□ Chlorine (Free/Total)
□ *Conductivity
□ *Cyanide, Free
□ Fluoride
□ *Hydrogen Sulfide
□ *Combined Nitrate + Nitrite
□ *Nitrate
□ *Nitrite
□ *Orthophosphate
□ pH
□ *Sulfate
□ *Surfactants
□ *Total Dissolved Solids
□ Total Hardness
□ *Turbidity
ORGANICS
□ *Total Organic Carbon
Collector's Name:
□ Owner
□ Operator
□ Aluminum
□ Antimony
□ Arsenic
□ Barium
□ Beryllium
□ Cadmium
□ Chromium
□ Copper
□ Iron
□ Lead
□ Magnesium
□ Manganese
□ Mercury
□ Nickel
□ Selenium
□ Silver
□ Sodium
□ Thallium
□ Zinc
□ Spring
□ Impoundment
□ Treated
□ Other:
For: CN
For: TOC
□ Special Purpose
□ Home Loan
□ NaOH □ C6H8O6
□ H3PO4
RECEIVED BY:
DATE/TIME RECEIVED:
□ Purchased
APPROVED CONTAINER:
□ Treated/Chlorinated
REQUIRED VOLUME:
CHAIN OF CUSTODY FORM:
□ YES
□ YES
□ YES
□ NO
□ NO
□ NO
TEMPERATURE WHEN RECEVIED:
METHOD OF SHIPPING UPON RECEIPT:
□ US MAIL
□ HAND DELIVERED
□ COURIER
□ OTHER
Rev/3.0