InorganicLabReportForm.pdf

Colorado Department of Public Health and Environment Compliance Assurance & Data Management Unit

REPORTING FORM FOR INORGANIC CONTAMINANTS ANALYSES

SAMPLER: FILL OUT ONE FORM FOR EACH SAMPLE

Are these results to be used to fulfill compliance monitoring requirements? YES or NO Is this a check or confirmation sample? YES NO

PWSID CO0 COUNTY: DATE COLLECTED: / /

SYSTEMS NAME:

SYSTEM MAILING ADDRESS:

Street address/PO Box CITY STATE ZIP

CONTACT PERSON: PHONE: ( )

SAMPLE COLLECTED BY: TIME COLLECTED: am/pm

ENTRY POINT (Finished Water) SAMPLE SOURCE WATER SAMPLE FOR ENTRY POINT SAMPLE PLEASE INDICATE: Chlorinated Other Treatment

Finished—Not Treated (No chlorine or other treatment)

STATE ENTRY POINT CODE: EP SOURCE(S) REPRESENTED:

DO SAMPLES NEED TO BE COMPOSITED BY THE LABORATORY? YES NO

NOTE: CHECK OR CONFIRMATION SAMPLES CANNOT BE COMPOSITED

For Laboratory Use Only Below This Line

LABORATORY SAMPLE #: CLIENT NAME or ID#

LABORATORY NAME

LAB PHONE #: ( ) DATE RECEIVED IN LABORATORY / /

COMMENTS:

PARAMETER RESULT in (mg/L)

MCL in (mg/L)

STANDARD

METHOD

Lab Report Limit (mg/L)

Lab MDL in (mg/L)

Date Analyzed

Antimony 0.006 Arsenic 0.010 Barium 2 Beryllium 0.004 Cadmium 0.005 Chromium 0.1 Cyanide 0.2 Fluoride 4.0 Mercury 0.002 Nickel ** Selenium 0.05 Sodium ** Thallium 0.002

** Monitoring is required, but there is no MCL for this contaminant Codes used:

NT = Not tested for compound mg/L = Milligrams per liter MCL = Maximum Contaminant Level Lab MDL = Laboratory Method Detection Level BDL = Indicates that the compound was analyzed for, but was below the Lab MDL.

Lab Report Limit = Level of Quantitation (LOQ).

Reviewed & Approved by Title Date

MAIL RESULTS TO: CDPHE, WQCD-CADM FAX: 303-782-0390

4300 Cherry Creek Drive South Denver, CO 80246-1530

INSTRUCTIONS AND EXAMPLES

**DO NOT TAKE SAMPLE FROM HOSES OR THROUGH SCREENS**

***DO NOT take your sample in the DISTRIBUTION SYSTEM***

SAMPLER:

• Fill out one form for each sample

• Fully complete the upper portion of the "REPORTING FORM FOR INORGANIC CONTAMINANTS ANALYSIS" and submit it to the laboratory with the filled sample bottle.

• Label each bottle correctly and completely. Please be sure you use the same description you used on the paperwork.

1. Are these results to be used to fulfill compliance-monitoring requirements? Check YES or NO

2. Is this sample a check or confirmation sample? Check YES or NO

3. Enter the following information in the appropriate blanks:

PWSID Number County Date of Sample Collection Systems Name System Mailing Address Contact Person’s Name and Phone Number Sampler’s Name Time Collected

4. Indicate if this is a finished water sample or a source water sample (source water samples cannot be used for compliance). Compliance sampling points are always AFTER ALL TREATMENT and before the first customer. Any exception must be approved in writing from the Inorganic Chemical Contaminants Rule Manager. If your system does not treat the water from deep-water wells, the finished and source sampling points may be the same. For compliance purposes check the box for “Finished—Not Treated.”

5. For Finished Water Samples Check the Appropriate Box Chlorinated Other Treatment Finished—Not Treated (No Chlorine or Other Treatment) (i.e., deep-water wells that have no disinfection)

6. Enter the State Entry Point Code: ALWAYS use state assigned facility id numbers. These are located on your annual monitoring schedule.

7. List the Source(s) Represented

Examples for numbers 6 and 7 above:

(6) SAMPLING POINTS (7) SOURCE(S)

EP-001 001-Well #1 (no treatment added) EP-002T 009-Clorinator for North spring EP-003T 007, 010, 011-North well Field Clearwell

It is important that you have a sampling tap at each entry point to the distribution system (EPTDS). If your system does not have a sampling tap at each EPTDS, every effort should be made to have one installed as soon as possible.

COMPOSITING:

• The regulations allow the LABORATORY, at your request, to composite more than one source, into one sample. (See below).

You must indicate that you want the laboratory to do this for you. This will reduce the overall cost of the monitoring, but the laboratory may add some additional fees to cover the costs of the additional sample bottle preparation and the compositing procedure.

• If compositing please describe all sampling points (provide state assigned ID numbers) being composited. If more than one system/establishment is compositing, include PWSID# for each system. Systems with a population greater than 3,300 may NOT composite with another system.

• Up to FIVE (5) sets of samples can be composited for Inorganic Contaminants.

• Check or Confirmation samples CANNOT be composited!

• If a contaminant is detected in a composited sample you may be required to resample. If you are required to resample, each source must be sampled and analyzed separately.

If you have an unusual situation that we have not covered in these instructions, or you have other sampling questions please call (303) 692-3500 and ask to speak to the Inorganic Contaminants Drinking Water Rule Manager.

INSTRUCTIONS AND EXAMPLES