DOMESTIC WATER QUALITY INDICATOR TESTS

 

REFRIGERATE SAMPLES AND DELIVER IN COOLER - SEE INSTRUCTIONS ON REVERSE SIDE PACKAGE WITHOUT LEAD $80 - PACKAGE INCLUDING LEAD $100

CHECK TESTS DESIRED - PLEASE SUBMIT PAYMENT WITH SAMPLES

 

 

Attention ____________________________             Delivered By _________________________________

Name ______________________________             Water Source _________Raw/Treated ____________

Address ____________________________             Collected By ________  

              ____________________________                          Company _______________

Phone/Fax __________________________             Collected Date _____________    Time ___________

Location ____________________________             Sample Point ________________________________

            _____________________________              Comments __________________________________

 

 

ANALYSES                                            MAXIMUM CONTAMINANT LEVEL                               RESULTS

 

_____  $25  Arsenic                                                    0.05 mg/l                                 __________    mg/l

_____  $15  Hardness (as CaCO3)                           250 mg/l                                  __________    mg/l

_____  $20  Iron                                                          0.3 mg/l                                   __________    mg/l

_____  $10  pH                                                            6.5 - 8.5                                  __________               

_____  $10  Total Dissolved Solids (Estimated)        500 mg/l                                  __________    mg/l

_____  $22  Nitrate-N                                                  10 mg/l                                    __________    mg/l

_____  $20  Lead                                            Action Level 0.015 mg/l                       __________    mg/l

 

_____  _______________________________                                                          __________    mg/l

_____  _______________________________                                                          __________    mg/l

_____  _______________________________                                                          __________    mg/l

 

 

$22

_____  Total Coliform Bacteria           Present ____________          Absent _________

            E. Coli (a Fecal Coliform)       Present ____________          Absent _________

            Coliform Analysis:       Date__________        Time ___________

 

Oregon Health Division: The presence of coliform bacteria indicates that other disease

causing organisms may also be present in the water and it may be unsafe to drink.

 MCLs taken from Oregon Administrative Rules for Public Water Systems 333-61-030.

 

 

APPROVED __________________________________________________________       DATE _________

 

Example Form