Form LSAD100F2.24 "Water Requisition" - Nova Scotia, Canada

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Download Form LSAD100F2.24 "Water Requisition" - Nova Scotia, Canada

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Agriculture and Food Protection
Tel: 902-893-6565 Fax: 902-893-4193
176 College Road, Truro NS B2N 2P3
http://www.novascotia.ca/agri/programs-and-
services/lab-services/
WATER REQUISITION
*Required Information
- Bacteria Water Samples MUST be received to Laboratory Services within 24 hours of sampling
- Water samples MUST be submitted Monday to Wednesday 8:30am – 3:00pm, and Thursday 8:30am – 1:00pm
- Bacteria Water Samples with color (brownish/yellowish, etc.) MUST be submitted before Wednesday at 3:00pm
- For additional information and full instructions on HOW TO TAKE A BACTERIA WATER SAMPLE, refer to the reverse side of this form
Client Mailing Information – PLEASE PRINT CLEARLY
COPY OF REPORT to (if different from mailing information)
Email ☐ Fax ☐ Mail ☐
Email ☐ Fax ☐ Mail ☐
*Type of report (check ONE only):
*Type of report (check ONE only):
*Name/Company:_________________________________________
*Name/Company:_________________________________________
*Address: _______________________________________________
________________________________________________________
*City/Town: ______________________*Postal Code: ____________
*Address: ___________________________________________ ____
*Telephone: ____________________ *Fax: ____________________
________________________________________________________
*Email: _________________________________________________
*Town/City: ___________________ *Postal Code: ______________
*Confirm email: __________________________________________
*Telephone: _________________ *Fax: ______________________
Sample Information – PLEASE PRINT CLEARLY
*Email: _________________________________________________
Drilled Well ☐
Dug Well ☐
Milk Water House ☐
*Confirm email: __________________________________________
*Date Sample Taken: _______________ *Time Taken: ___________
*Registered Drinking Water # (if applicable):
*Sample location (pond, tap, etc): ____________________________
________________________________________________________
*Address of Water Source: _________________________________
*Client Signature: _________________________________________
________________________________________________________
Select Test(s) Requested
OFFICE USE ONLY:
REFER TO ANALYTICAL FEE SCHEDULE FOR PRICING AND FULL LIST OF
AVAILABLE TESTING
Received at Regional Office (if applicable): _____________________
Bacterial Analysis:
Order ID:
(requires sterile, approved container obtained from Lab Services)
☐ P/A (Present/Absent – coliform/E. coli)
☐ MPN (Estimated count of bacteria – coliform/E. coli)
Mineral Analysis:
(requires 250mL bottle obtained from Lab Services)
Standard W1 Water Package
(Ca, Mg, K, Na, Cl, SO
, Fe, Mn, Cu, Zn, Ba, B, Cd, Cr, Al, pH, NO
+NO
-N,
4
3
2
Temperature (°C): _____________ Initials (Receiver): ____________
Alkalinity, Conductivity and Hardness)
Mineral Testing
Date Stamp (received at Lab): _______________________________
(Ca, Mg, K, Na, SO4, Fe, Mn, Cu, Zn, Ba, B, Cd, Cr, Al and Hardness)
Yes ☐
No ☐
Attempt ☐
Security String Used:
Additional Analysis:
Uranium
Client Called: ☐
NSE Called: ☐
Lead *
Date: ______________ Time: _____________ Initials: ___________
Arsenic *
Other (please specify):
Comments:
________________________________________________________
________________________________________________________
*one additional 250mL sample bottle is required for lead and/or
________________________________________________________
arsenic analysis.
LSAD100F2.24
Agriculture and Food Protection
Tel: 902-893-6565 Fax: 902-893-4193
176 College Road, Truro NS B2N 2P3
http://www.novascotia.ca/agri/programs-and-
services/lab-services/
WATER REQUISITION
*Required Information
- Bacteria Water Samples MUST be received to Laboratory Services within 24 hours of sampling
- Water samples MUST be submitted Monday to Wednesday 8:30am – 3:00pm, and Thursday 8:30am – 1:00pm
- Bacteria Water Samples with color (brownish/yellowish, etc.) MUST be submitted before Wednesday at 3:00pm
- For additional information and full instructions on HOW TO TAKE A BACTERIA WATER SAMPLE, refer to the reverse side of this form
Client Mailing Information – PLEASE PRINT CLEARLY
COPY OF REPORT to (if different from mailing information)
Email ☐ Fax ☐ Mail ☐
Email ☐ Fax ☐ Mail ☐
*Type of report (check ONE only):
*Type of report (check ONE only):
*Name/Company:_________________________________________
*Name/Company:_________________________________________
*Address: _______________________________________________
________________________________________________________
*City/Town: ______________________*Postal Code: ____________
*Address: ___________________________________________ ____
*Telephone: ____________________ *Fax: ____________________
________________________________________________________
*Email: _________________________________________________
*Town/City: ___________________ *Postal Code: ______________
*Confirm email: __________________________________________
*Telephone: _________________ *Fax: ______________________
Sample Information – PLEASE PRINT CLEARLY
*Email: _________________________________________________
Drilled Well ☐
Dug Well ☐
Milk Water House ☐
*Confirm email: __________________________________________
*Date Sample Taken: _______________ *Time Taken: ___________
*Registered Drinking Water # (if applicable):
*Sample location (pond, tap, etc): ____________________________
________________________________________________________
*Address of Water Source: _________________________________
*Client Signature: _________________________________________
________________________________________________________
Select Test(s) Requested
OFFICE USE ONLY:
REFER TO ANALYTICAL FEE SCHEDULE FOR PRICING AND FULL LIST OF
AVAILABLE TESTING
Received at Regional Office (if applicable): _____________________
Bacterial Analysis:
Order ID:
(requires sterile, approved container obtained from Lab Services)
☐ P/A (Present/Absent – coliform/E. coli)
☐ MPN (Estimated count of bacteria – coliform/E. coli)
Mineral Analysis:
(requires 250mL bottle obtained from Lab Services)
Standard W1 Water Package
(Ca, Mg, K, Na, Cl, SO
, Fe, Mn, Cu, Zn, Ba, B, Cd, Cr, Al, pH, NO
+NO
-N,
4
3
2
Temperature (°C): _____________ Initials (Receiver): ____________
Alkalinity, Conductivity and Hardness)
Mineral Testing
Date Stamp (received at Lab): _______________________________
(Ca, Mg, K, Na, SO4, Fe, Mn, Cu, Zn, Ba, B, Cd, Cr, Al and Hardness)
Yes ☐
No ☐
Attempt ☐
Security String Used:
Additional Analysis:
Uranium
Client Called: ☐
NSE Called: ☐
Lead *
Date: ______________ Time: _____________ Initials: ___________
Arsenic *
Other (please specify):
Comments:
________________________________________________________
________________________________________________________
*one additional 250mL sample bottle is required for lead and/or
________________________________________________________
arsenic analysis.
LSAD100F2.24
Agriculture and Food Protection
Tel: 902-893-6565 Fax: 902-893-4193
176 College Road, Truro NS B2N 2P3
http://www.novascotia.ca/agri/programs-and-
services/lab-services/
Nova Scotia Environment recommends bacterial testing of water quality at least every six months and chemical testing of water quality
at least every two years.
Please note: Samples are analyzed as provided. The laboratory takes no responsibility for the accuracy of the information provided by
the person submitting the sample (e.g. location, date and time taken, etc.). Lab Services reserves the right to refuse samples collected
in unissued bottles, samples with an odor of chlorine, or samples containing foreign material. Laboratory Services is a testing facility
only. It is up to individual clients to determine what testing they require.
Report of results will ONLY be provided in the format selected (email, fax or mail).
Bacteria samples submitted after 3pm will not be entered into the system until the next business day.
INSTRUCTIONS ON HOW TO TAKE A BACTERIA WATER SAMPLE
1.
Remove the screen from the faucet. Clean the inside and outside of the tap opening with rubbing alcohol.
2.
Run cold water for 3 to 5 minutes.
3.
Before taking the sample, reduce the flow rate to approximately the width of a pencil before taking the sample. The flow rate
should be low enough to ensure that no splashing occurs as the container is filled.
FLIP TOP VIAL:
1.
Open sterile container by pushing up cap tabs. NOTE: DO NOT remove pill from the container! (The color of the pill can range
from white to dark grey or purple, and it may be speckled in appearance. This is normal.)
2.
Fill the container ABOVE the EPA 100mL fill line. Samples containing less than 100mL WILL BE REJECTED.
3.
Close the container by pressing the cap from the hinge location and pushing it forward. It should securely snap shut.
4.
Close the tab, then pull the string through the round hole on the post. This will lock the vial.
4.
Read all submission requirements on the front of this water sample submission sheet, above the signature line.
5.
Ensure that all relevant sections on the front of this water sample submission sheet are completed. Submit this form along
with your water sample.
SCREW TOP VIAL:
1.
While holding the sample container at the base, remove the seal around the cap before attempting to open the bottle.
2.
Remove the cap with the free hand. Be careful NOT TO TOUCH the inside of the bottle cap or bottle lip. Continue to hold the
cap in one hand with the inside facing down while the bottle is being filled. Do not touch the inside of the cap or lay it down.
3.
NOTE: Sample bottle contains a powder preservative. DO NOT rinse the bottle.
4.
Fill the bottle ABOVE the 100mL fill line. DO NOT allow the bottle to overflow.
5.
Carefully replace the cap and entire it is screwed on securely.
6.
Read all submission requirements on the front of this water sample submission sheet, above the signature line.
7.
Ensure that all relevant sections on the front of this water sample submission sheet are completed. Submit this form along
with your water sample
All bacteria samples must be transported to the laboratory within 24 hours of sampling. It is recommended that samples be kept at less
than 10°C until delivered to the laboratory.
LSAD100F2.24
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