Form DPH-FL-C "Massachusetts Department of Public Health Monthly Distribution System Split Testing Fluoridation Report" - Massachusetts

What Is Form DPH-FL-C?

This is a legal form that was released by the Massachusetts Department of Environmental Protection - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 12, 2007;
  • The latest edition provided by the Massachusetts Department of Environmental Protection;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DPH-FL-C by clicking the link below or browse more documents and templates provided by the Massachusetts Department of Environmental Protection.

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Download Form DPH-FL-C "Massachusetts Department of Public Health Monthly Distribution System Split Testing Fluoridation Report" - Massachusetts

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MASS/DEPARTMENT OF PUBLIC HEALTH
DPH-FL-C
(monthly)
MONTHLY DISTRIBUTION SYSTEM SPLIT TESTING FLUORIDATION REPORT
Month of __________, 20__ __
Page __ of __
The data from this report will be used to evaluate the accuracy of the PWS fluoride testing equipment or laboratory.
1
Each month, at least one (1) distribution sample must be split and analyzed by the PWS and a Mass. laboratory certified for fluoride.
Any questions, please call the Mass DPH Fluoridation Program at 617-624-5573.
Section I. PWS SAMPLING INSTRUCTIONS (PWS are required to take the following actions)
1. Collect a fluoride sample from the location checked on Form FL-B.
2. Divide the sample into two. The PWS must analyze one portion (“A”) for fluoride using Std. Methods approved analytical method
for fluoride analysis. e.g. specific ion or colorimetric method. The other portion of the sample (“B” or “split sample”) must be sent
1
for analysis within 96 hours of collection, to a laboratory that is certified by MassDEP for fluoride analysis.
3. Record below, in Section II, all requested information for portion “A”.
Section II. PWS INFORMATION: (To be completed and signed by PWS)
1. PWS Name:
_____________________ 2. PWS ID#:
____________ 3. City/Town or District:
________________
4. List all contributing fluoridated source(s)/MassDEP Source Code/Location ID:
______________________________________
5. Name of PWS operator performing sample analysis:
__________________________________________________________
6. Make and Model # of PWS fluoride analyzer:
________________________________________________________________
Sample # or Location Name & Address
Results
Sample Collector’s Name
Date Sample
Date Sample
from Form FL-B
(PPM)
Collected by
Analyzed by
Bottle #
(Print)
PWS
PWS
(To the
nearest 0.1)
I certify under penalty of law that I am the person authorized to fill out this form and the information contained herein is true, accurate
and complete to the best of my knowledge and belief.
________________________
___________________
Name of PWS operator or responsible party:
Signature:
Date:
_____________
Phone #:
___________________Fax#:
______________________ Email address:
_________________________________________
Section III. LABORATORY ANALYTICAL INFORMATION: (To be completed and signed by Lab)
Lab name:
____________________ MassDEP Lab Cert.#:
___________ Lab phone:
_____________
Lab address:
___________________________________________________________________________________
Is this lab certified by MassDEP for fluoride analysis?
subcontracted lab used?
Yes
No
. If no, is a
Yes
No
Subcontracted lab name:
____________Sub lab MassDEP Cert #:
____________
Is this subcontracted laboratory certified by MassDEP for fluoride analysis?
Yes
, No
Sample
Sample Location
Bottle #
Lab sample
Results (PPM)
Detection
Analytical
Date
ID#
Location
limit
Method
Analyzed
Name & Address
(To the nearest 0.1)
No.
.
My certified analytical results for the sample listed by the PWS as 01F is
___
___
___ PPM.
:
My laboratory result is Within
Check the correct answer
+/- 0.1 of the result listed by the PWS for 01F.
My laboratory result is Not W
ithin +/- 0.1 of the result listed by the PWS for 01F.*
*PWS must contact the Office of Oral Health at 617-624-5573 within 7 days of learning of this checked result.
I certify under penalty of law that I am the person authorized to fill out this form and the information contained herein is true, accurate
and complete to the best of my knowledge and belief.
Name of Laboratory Director: _
_______________________Signature: ________________________ Date:
___________
1
If a PWS uses a Mass. certified lab for its daily samples it must use a different Mass. certified lab. for the required split sample.
Section IV. DPH USE ONLY
Date received
________ Approved:
_____ Deficient/Comments:
_______________________________________________________
Within 30 days of receipt of results and no later than 10-days after the end of the reporting period, PWSs approved by MassDEP for
Fluoridation treatment must mail 1 copy of each page of this report form (A, B, & C) to: MA Dept. of Public Health, 250 Washington
th
Street, 5
Floor, Boston, MA 02108-4619 Att: Office of Oral Health
DPH FL-C 2-12-07
MASS/DEPARTMENT OF PUBLIC HEALTH
DPH-FL-C
(monthly)
MONTHLY DISTRIBUTION SYSTEM SPLIT TESTING FLUORIDATION REPORT
Month of __________, 20__ __
Page __ of __
The data from this report will be used to evaluate the accuracy of the PWS fluoride testing equipment or laboratory.
1
Each month, at least one (1) distribution sample must be split and analyzed by the PWS and a Mass. laboratory certified for fluoride.
Any questions, please call the Mass DPH Fluoridation Program at 617-624-5573.
Section I. PWS SAMPLING INSTRUCTIONS (PWS are required to take the following actions)
1. Collect a fluoride sample from the location checked on Form FL-B.
2. Divide the sample into two. The PWS must analyze one portion (“A”) for fluoride using Std. Methods approved analytical method
for fluoride analysis. e.g. specific ion or colorimetric method. The other portion of the sample (“B” or “split sample”) must be sent
1
for analysis within 96 hours of collection, to a laboratory that is certified by MassDEP for fluoride analysis.
3. Record below, in Section II, all requested information for portion “A”.
Section II. PWS INFORMATION: (To be completed and signed by PWS)
1. PWS Name:
_____________________ 2. PWS ID#:
____________ 3. City/Town or District:
________________
4. List all contributing fluoridated source(s)/MassDEP Source Code/Location ID:
______________________________________
5. Name of PWS operator performing sample analysis:
__________________________________________________________
6. Make and Model # of PWS fluoride analyzer:
________________________________________________________________
Sample # or Location Name & Address
Results
Sample Collector’s Name
Date Sample
Date Sample
from Form FL-B
(PPM)
Collected by
Analyzed by
Bottle #
(Print)
PWS
PWS
(To the
nearest 0.1)
I certify under penalty of law that I am the person authorized to fill out this form and the information contained herein is true, accurate
and complete to the best of my knowledge and belief.
________________________
___________________
Name of PWS operator or responsible party:
Signature:
Date:
_____________
Phone #:
___________________Fax#:
______________________ Email address:
_________________________________________
Section III. LABORATORY ANALYTICAL INFORMATION: (To be completed and signed by Lab)
Lab name:
____________________ MassDEP Lab Cert.#:
___________ Lab phone:
_____________
Lab address:
___________________________________________________________________________________
Is this lab certified by MassDEP for fluoride analysis?
subcontracted lab used?
Yes
No
. If no, is a
Yes
No
Subcontracted lab name:
____________Sub lab MassDEP Cert #:
____________
Is this subcontracted laboratory certified by MassDEP for fluoride analysis?
Yes
, No
Sample
Sample Location
Bottle #
Lab sample
Results (PPM)
Detection
Analytical
Date
ID#
Location
limit
Method
Analyzed
Name & Address
(To the nearest 0.1)
No.
.
My certified analytical results for the sample listed by the PWS as 01F is
___
___
___ PPM.
:
My laboratory result is Within
Check the correct answer
+/- 0.1 of the result listed by the PWS for 01F.
My laboratory result is Not W
ithin +/- 0.1 of the result listed by the PWS for 01F.*
*PWS must contact the Office of Oral Health at 617-624-5573 within 7 days of learning of this checked result.
I certify under penalty of law that I am the person authorized to fill out this form and the information contained herein is true, accurate
and complete to the best of my knowledge and belief.
Name of Laboratory Director: _
_______________________Signature: ________________________ Date:
___________
1
If a PWS uses a Mass. certified lab for its daily samples it must use a different Mass. certified lab. for the required split sample.
Section IV. DPH USE ONLY
Date received
________ Approved:
_____ Deficient/Comments:
_______________________________________________________
Within 30 days of receipt of results and no later than 10-days after the end of the reporting period, PWSs approved by MassDEP for
Fluoridation treatment must mail 1 copy of each page of this report form (A, B, & C) to: MA Dept. of Public Health, 250 Washington
th
Street, 5
Floor, Boston, MA 02108-4619 Att: Office of Oral Health
DPH FL-C 2-12-07