Environmental Laboratory Samples Form
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1
2ENVIRONMENTAL LABORATORY
P.O. Box 4369, Helena, MT 59604
1400 Broadway, Helena, MT 59620
Phone: (406) 444-2642
Toll-Free (800)
821-7284
REVISED 8/2011
Fax: (406) 444-2617 Email: MTPHL@MT.Gov
ALL INFORMATION MUST BE COMPLETED FOR ANALYSIS – PLEASE SELECT TESTS ON BACK OF FORM
/
/
2
0
COLLECT DATE:
ENVIRONMENTAL LABORATORY FEE SCHEDULE
PWSID or Account #: _______________
-- Effective through June 30, 2012 --
:
AM
PM
COLLECT TIME:
COLLECT BY:
-
(
)
PHONE NO:
Sampling Location: _____________________________________ Sample Source:
Well
Spring
Other:______________
(Kitchen tap, well head, bathroom sink, etc.)
EP
Dist. System
COMPLETED RESULTS TO BE SENT TO (Please PRINT one letter per box):
BILL TO (If different from Results Address):
_________________________________________
Name
Name
_________________________________________
Address
Address
_________________________________________
City
State
Zip
City
State
Zip
COPY of results sent to:
_________________________________________
County
Name
-
(
)
_________________________________________
Address
Phone
_______________________________________________________
_________________________________________
City
State
Zip
Email Address:(If you want your report emailed)
LAB USE ONLY IN THIS BOX
Date Rec’d: _____________________ Amount Rec’d: _____________
SAMPLE TYPE:
Water
Soil
Paint
Fish
Fuels
Urine Other: ________
Time Rec’d: _____________________ Check #: __________________
Sample pH: ___________________
Rec’d By: ______________________ Date Check Written: _________
Sample Temperature: ___________
Sample Conductivity:___________
Checked by: __________
Sample Turbidity:______________
Number of Bottles Received:
Common
Wet
DW 508
VOC
WellPest
BacT
Nutrients
Metals
DW 515
DW 531
DW 552
WellHerb
Ions
Chem
DW 525
THM
WellPetro
Preserved
Holding times observed?
Y N
SPLITS: (mL)
pH Check:
Preserved in?
with?
- Under 48 hours for IC?
Y N
Lachat: :
50
250
Metals:
L
F
HNO3
Sample containers in acceptable
Y N
condition?
IC
50
250
Nutrients:
L
F
H2SO4
Sufficient sample volume for all tests?
Y N
Metals:
50
250
Other:
L
F
Chain of Custody Level:
1 2 3
SPC
50
250
- Chain of Custody intact?
Y N
Lab #:
Commons
50
250
VOC/THM zero headspace?
Y N
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