Burlington WA 1620 S Walnut St. – 98233 • 800.755.9295 Corvallis OR

OREGON DRINKING WATER
SAMPLE INFORMATION
Burlington WA
1620 S Walnut St. – 98233 • 800.755.9295
Corvallis OR
540 SW 3rd St – 97333 • 541.753.4946
Wilsonville OR
9150 SW Pioneer Ct. Ste. W – 97070 • 503.682.7802
Report To:
Bill To:
Address:
Address:
City:
State:
Phone:
Zip:
For Lab Use Only
EDGE JCN
Ref#:
Same As Report To
City:
Fax:
State:
Zip:
Phone:
Email:
P. O. #
Contact:
VISA
Project Name:
CARD #
M/C
EXPIRES
/
SAMPLING INFORMATION REQUIRED
Investigative
Compliance - is for State regulations for Public Water Systems. (Results will be sent to you and the State.)
Date Collected:
Time Collected:
AM
PM
Collected By:
Sample address:
Source: (well, city water, spring, stream, other)
Specific Location: (Outside faucet, kitchen faucet, bath faucet, other)
PUBLIC WATER SYSTEM (ONLY)
System ID Number:
County:
System Name:
Sample Taken :
Treatment Type:
Residual Chlorine:
At source (SRC-______)
None
At Entry Point (EP-______)
Chlorination
In Distribution (DIST-_____)
Other
mg/L
Sample type: routine, special, assessment, other:
ANALYSIS TO PERFORM
Initial Positive ID#:
Date of Initial Positive:
FREQUENTLY REQUESTED TESTS. FOR OTHERS, PLEASE LIST UNDER OTHER ANALYSIS.
Bacteriology
Public Water Systems
Other Analysis:
Total Coliform & E. coli - Presence/Absence
SOC OR panel
Peace of Mind, no pesticides
________________________________
VOC OR panel
Peace of Mind, with pesticides
IOC OR panel
Water Treatment Package
Nitrate
552.3 Haloacetic Acids (HAA5)
Nuisance Package
Arsenic
524.2 Trihalomethanes (TTHM)
_________________________
Metals (List or circle each metal Individually) *
Lead and Copper Rule (Special Sampling)
_________________________
________________________________
______________________________
_________________________
________________________________
______________________________
_________________________
Inorganic Compounds
*METALS: Al,
Sb, As, Ba, Be, B, Cd, Ca, Cr, Co, Cu, Fe, Pb, Mg, Mn, Hg, Mo, Ni, K, Se, Si, Ag, Na, Sr, Tl, Sn, Ti, U, V, Zn
Turnaround Time Requested (Inorganic Compounds Only)
STANDARD - 10 BUSINESS DAYS
HALFTIME - 5 BUSINESS DAYS (SURCHARGE APPLIES)
QUICKEST - 3 BUSINESS DAYS (SURCHARGE APPLIES)
Remarks or Special Instructions:
RELINQUISHED BY
DATE
TIME
X
RECEIVED BY
DATE
TIME
X
YES
CUSTODY SEALS INTACT
EVIDENCE OF COOLING
o
SAMPLE TEMP________ C SATISFACTORY
SAMPLES RECEIVED INTACT
CHAIN OF CUSTODY & LABELS AGREE
WSI FORM Revised.doc 02/21/2014
NO
N/A
PAYMENT:
INVOICE
CASH
CREDIT CARD
CHECK #________
AMOUNT $________
GENERAL INSTRUCTIONS ARE ON THE BACK
GENERAL INSTRUCTIONS FOR COLLECTING & SHIPPING WATER SAMPLES
1. Handle Samples containers as follows:



Do not touch the inside of the container or cap.
Do not let the container touch the faucet.
Do not set the cap down where it may become contaminated.
2. If you are taking a chemical compliance sample for public water system, it should be taken from a point
representative of the source; after treatment and prior to entry to the distribution system. Bacterial
compliance samples are usually taken in the distribution system: see your routine coliform sampling plan.
3. Other samples may be taken from the well or from a household faucet.
4. The tap or spigot where you draw water should be free of contaminating devices such as filters, screens or
aeration devices. Do not take the sample from a hose or from a hot water tap.
5. Flush the system for several minutes to ensure that water from the tap represents the water source. The
water temperature should stabilize.
6. If you are going to hand deliver the sample, do so immediately or place the sample in the refrigerator until
you transport the sample and the sample must be brought to the laboratory on ice.
7. You may use the drop box before 9:00 am at the Corvallis location.
8. If you are going to ship the sample, pack it in sufficient double-bagged ice to maintain a temperature of 4OC
until it arrives at the lab. Water samples must be kept cold (4OC) but not frozen during transport.
9. Ship samples within 8 hours of collection. Using overnight service insures sample receipt within 24 hours.
10. General Sampling Instructions at: http://www.edgeanalytical.com/pages/resources/sampling_instructions/
**********THE LAB MUST RECEIVE SAMPLES ON ICE WITHIN 24 HOURS AFTER COLLECTION**********
Return
samples to ►
Edge Analytical Laboratories/Corvallis
540 SW 3rd St.
Corvallis, OR 97333
Return
samples to ►
Edge Analytical Laboratories/Portland Branch
9150 SW Pioneer Ct Ste W
Wilsonville, OR 97070
If you are dropping off or shipping your sample, please attach payment, checks only, no
cash, to sample bottle with a rubber band. Make checks payable to Edge Analytical. You
may call the laboratory with credit card information for Visa or MasterCard payments.
www.edgeanalytical.com