WATER QUALITY LABORATORY
“PROGRESS THROUGH KNOWLEDGE”
Shipping address and physical location
Water Quality Laboratory
Oklahoma Panhandle State U.
Science and Agriculture Building – Room 108
417 W. Sewell St.
Goodwell, OK 73939 / Mailing address
Water Quality Laboratory
Oklahoma Panhandle State U.
P.O. Box 430
Goodwell, OK 73939 / Telephone
580-349-1563 / Email
Fax
580-349-1567 / Website
Individual or Company Name / ‘BAC-T’ SAMPLE SUBMISSION FORM
PWSID # / REGULATORY ACTIONS
Mailing address / REGULATORY RULE
Test result / ACTION / Name/Date/Time
of lab action
TCR
Routine sample
Total coliform positive /
- Lab notifies client. Advises client to:
- Resample distribution system within 24 hours (per TCR)
- GWR “triggered source sample” collected within 96 hours from original sample
- Lab notifies ODEQ
Contact name
Telephone / GWR
Total coliform positive /
- Lab notifies client
- Lab notifies ODEQ
E-mail / Report by
e-mail / GWR
E. coli positive /
- Lab notifies client
- Lab notifies ODEQ and USEPA
- GWR “corrective action sample” collection per EPA instructions
REGULATORY INFORMATION / COLLECTION / Volume MUST BE ≥100 mL and ≤120 mL.
See volume marks on the sample bottle. / Lab Use
TC = Total Coliform Rule GE = Ground Water Rule
NC = Not for compliance / RT = Routine
RP = Repeat
SP = Line test / OR = Original site
UP = Upstream within 5 connects
DN = Downstream within 5 connects
NF = Near first service OT = Other / LOCATION CODE / CHLORINE
Enter
mg/L valueandindicate free or total, OR
> NA indicating not from chlorinated system / SAMPLE
IDENTIFICATION / BY / DATE / TIME / Received by / Date / Time
RULE CODE / TYPE CODE / IF REPEAT SAMPLE, ENTER RELATION TO ORIGINAL SAMPLE / FACILITY ID / Receipt
Temp / Temp
Adj / Actual
Temp / Cl2 / LIMS
Sample #
Chain-of-Custody > / Relinquished by/Date/Time / Received by/Date/Time / Received by/Date/Time
QS.FORM.SAMPLE.BAC-T.ROUTINE_USER.003 / Page 1 of 1