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