Form Dhhs-2887 - Public Water Supply Regional Office Request - N.c. Department Of Health And Human Services
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1
2N.C. Department of Health and Human Services
State Laboratory of Public Health
4312 District Drive • P.O. Box 28047
Raleigh, NC 27611-8047
PUBLIC WATER SUPPLY REgIonAL offICE REqUEST
Complete All Items – Please Print Clearly
Read Instructions on Reverse Side Prior to Sample Collection
*-Indicates Required Fields
Water System I.D. number
-
-
*Name of System:
Type of System: ____ Community
____ Non-Community
Sampling Address: ______________________________________
Source of Water: Ground
Both
Surface Purchased
____________________________________ Zip ______________
*Report To: ____________________________________________
Type of Sample: ____ Raw ____ Treated
Address: ______________________________________________
Type of Treatment: _____________________________
____________________________________ Zip ______________
____________________________________________
EIN #_________________________________________________
____________________________________________
Sampling Point: _____________________________ *Date Collected: ______________ *Time Collected: ____________
Collected By: _________________________________________________________
Place a check in the box to request analyses for all parameters in the group or select individual parameters by circling
the parameter(s) desired.
Regular Parameters
Additional Metals group
Additional Water Parameters
pH
Cadmium
Acidity
Alkalinity
Chromium
Color
Fluoride
Mercury
Sodium
Chloride
Selenium
Sulfate
Calcium
Silver
Turbidity
Total Hardness
Barium
Total Dissolved Solids
Manganese (Total)
Antimony
Lead
Beryllium
Arsenic
Thallium
Copper
Iron (Total)
optional Parameters: List Optional Parameters Below
Magnesium
Zinc
________________________________________________________________
________________________________________________________________
Total & Soluble fe & Mn
Iron
________________________________________________________________
Manganese
Comments: _________________________________________________________________________________________
___________________________________________________________________________________________________
Laboratory Use only
Received By: _____________________________________________________ Mail
Courier
Walk In
DHHS 2887 (Revised 04/13)
Laboratory (Review 04/16)
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