
Draft
June
2003
Long­
Term
2
Enhanced
Surface
Water
Treatment
Rule
(
LT2
Rule)
Sample
Collection
Form
Utility
Information
Shipping
Information
For
Lab
Use
Only
PWS
name:

PWS
address:
Lab
name:

Lab
address:
Date
received:

Time
received:

Received
by:

Sample
temperature
on
receipt:

Sample
condition
on
receipt:
Sampler
name:
Date
shipped:

Sample
Identification
Information
(
the
combination
of
bolded
items
are
used
to
identify
the
sample
under
LT2)

Sample
ID
(
optional):

PWS
ID:

Facility
ID:

Facility
name:

Sample
collection
point
ID:

Sample
collection
point
name:

Sample
collection
date:

Source
water
typea
(
circle
one):
Flowing
stream
(
FS)
Reservoir/
lake
(
RL)

GWUDIb
­
FS
GWUDIb
­
RL
Requested
analysis
(
circle
one):
Cryptosporidium
field
sample
Cryptosporidium
matrix
spike
E.
coli
Sample
Collection
Information
Cryptosporidium
E.
coli
Initial
meter
reading
(
field­
filtered
samples
only):
Sample
collection
time:

Sample
collection
time
(
or
start
time,
if
field
filtering):
Turbidity
(
NTU):

Sample
collection
stop
time
(
field­
filtered
samples
only):

Final
meter
reading
(
field­
filtered
samples
only):

Additional
comments:

Sampler
signature:
Date:

a
The
source
water
type
should
be
selected
based
on
the
type
of
source
water
that
accounts
for
the
majority
of
the
surface
water
used
as
source
water
at
the
time
of
sample
collection
b
Ground
water
under
the
direct
influence
of
surface
water
