TWISS ANALYTICAL LABORATORIES, INC

DRINKING WATER SAMPLE INFORMATION (WSI) FOR

DISINFECTION BY-PRODUCTS

Read the sampling instructions on the back of this form before sampling.

Please fill out the form completely.

 524.2 Total TrihalomethanesLaboratory Number: ______

 552.1 Haloacetic AcidsLaboratory Number: ______

1. System ID No: / 2. System Name: / 3. Group (circle one)
A B Private/Other
4. Sample Location: / 5. Date/Time Collected: AM/PM
6. Sample Collected By: / 7. Sampler Phone Number: / 8. Sample Type: (Check one)
Pre-Treatment (raw)
Post-Treatment/Finished
 Unknown
9. County: (circle one)
Kitsap Clallam Jefferson Mason Pierce Thurston Island King Grays Harbor
Other: / 10. Sample Purpose:
 Routine Compliance
 Confirmation
 Investigative
 Other / 11.SampleComposition
 Single Source
 Blended
 Composite
 Distribution /
  1. Source No (s):
S 92
______, ______,
______, ______,
______, ______
13. Send Report To: (Print Name, Address, Zip Code) / 14.Phone No.:
15. Fax No.:
16. Email:
17. Special Instructions/Comments:
Sample Relinquished By: / Date /Time: / Condition on Receipt:
Sample Received By: / Date /Time: / Temperature On Receipt:

Sampling Instructions

Haloacetic Acids (HAA5)/Total Trihalomethane (TTHM)

Please read instructions prior to sampling

Collection Point

HAAs and THMs should be collected in accordance with 40 CFR 141.132 (b) (1). They should be sampled from the same collection point and preferably at the same time. Samples should be collected within the distribution system, not at the source or treatment plant.

Sample Collection – Haloacetic Acids (HAA5)

  1. Fill completely one (1) 250ml brown glass bottle. If water taps are to be used for sampling, all aerators, strainers, and hose attachments need to be removed.
  2. Open the tap and allow the system to flush until the water temperature stabilizes.
  3. Fill bottle completely, taking care not to flush out the sample preservative.
  4. Fill out the bottle label and complete the Water Sample Information form in pen. Put the sample on ice in a cooler.

Sample Collection – Total Trihalomethane (TTHM)

  1. Collect two (2)40ml vials.
  2. If water taps are to be used for sampling, all aerators, strainers, and hose attachments need to be removed.
  3. Open the tap and allow the system to flush until the water temperature stabilizes.
  4. Fill two (2)40mL vials from each collection point, one immediately after the other, under the same conditions. Avoid agitation of the sample while filling. Allow the stream of water to gently flow into the vial until the vial is half full. DO NOT LET THE VIALS TOUCH THE FAUCET OR SPIGOT AS THE SAMPLE MAY BECOME CONTAMINATED.
  5. After filling half way, empty the insertin one of the red-capped 2mL vials into each 40mL vial. Caution: these inserts contain HCl; HCl is corrosive.DO NOT put the red-capped vial in TTHM vial, only the insert. Gently add more water so that the water level is slightly above the top of the vial prior to capping.
  6. Carefully place the cap onto the 40mL vial and tighten down securely.
  7. Check for trapped air by inverting the vial and looking for any air bubbles. If air bubbles are present, carefully remove the cap and gently add more water. The lab will reject TTHM samples if there are air bubbles in the container. This will result in re-sampling. When you are sure the vial is properly filled, shake vigorously.
  8. Fill out the bottle labels and complete the Water Sample Information form in pen for each sample. Put the sample on ice in a cooler.

After Sample Collection

All samples must be kept cold (4oC). Complete the Sample Information form (WSI) and return to the lab within 24 hours.

26276 Twelve Trees Lane, Suite C  Poulsbo, WA98370  (360) 779-5141  Fax: (360) 779-5150

S:\Templates\Sample Management\Current Forms\THM HHA form-instructions 031313.docRevision date 031313