OKLAHOMA PANHANDLE STATE UNIVERSITY / / MURPHY-BROWN LLC 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
/ Certifications
USEPA: OK01026
ODEQ: D9938
KDHE: E10394
TCEQ: T104704496
Fax
580-349-1567 / Website
www.waterlab.opsu.edu
Individual or Company name / PWSID# / ‘BAC-T’ SAMPLE SUBMISSION FORM
Mailing address / Test Result / REGULATORY ACTIONS
for Compliance Monitoring Samples
If Routine TC+ / ·  Lab notifies client. Advises client to:
o  Resample distribution system within 24 hours of learning of TC+
o  GWR “triggered source sample” collected within 96 hours from original sample
Contact name / Telephone
If GWR TC+ / ·  Lab notifies client
·  Lab notifies state agency
Fax
/ Email
/ Mail
/ Indicate report and billing preference / If GWR EC+ / ·  Lab notifies client
·  Lab notifies state agency
·  Client contacts USEPA
For COMPLIANCE MONITORING SAMPLES / SAMPLE COLLECTION / Received by / Date / Time
TCR=Total Coliform Rule
GWR=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 / Enter below
mg/L value
indicate free or total
OR
NC for
non-chlorinated system / Volume MUST BE ≥100 mL and ≤120 mL,
with air space remaining (i.e. not liquid full).
See volume marks on the sample bottle. / / Normal receipt
/ Found on desk/hallway
NF = Near first service
OT = Other
IF REPEAT SAMPLE / RT sample must be from facility DS (distribution system) or POE (point of entry). GWR sample must be from WL (well). / / COC form completed at time of receipt
/ Received from person other than collector or by shipment
/ Received with solid ice present
RULE
CODE / TYPE
CODE / (Type=RP)
Enter relation
to original sample,
otherwise leave blank / FACILITY
ID / LOCATION
CODE / CHLORINE / SAMPLE IDENTIFICATION / BY / DATE / TIME / / Container coding/labeling needed correction
Receipt
Temp / Temp
Adj / Actual
Temp / Cl2 / LIMS
Sample #
Chain-of-Custody / Relinquished by/Date/Time / Received by/Date/Time / Received by/Date/Time
CONTROLLED DOCUMENT WHEN DATA ENTERED / QS.FORM.SAMPLE.BAC-T.ROUTINE_USER / Version: / 008 / Issued: / 21-Jun-2012 / Page 1 of 1