Ohio



CHEMICAL - RADIOLOGICAL (RAD)

SAMPLE SUBMISSION REPORT (SSR)

Division of Drinking and Ground Waters

Central Office

50 W Town St

Columbus Ohio 43215

(614) 644-2752 FAX (614) 644-2909

PUBLIC WATER SYSTEM INFORMATION:

PWS ID: OH      

PWS Name:      

STU ID:      

STU Name:      

Address:      

City, State, Zip:      

County:      

LABORATORY INFORMATION:

Reporting Lab Name:      

Reporting Lab Certification No.:      

Lab Sample Number:      

Comments

     

SAMPLE INFORMATION:

Sample Monitoring Point:      

Sample Type:

-- Routine (compliance)

-- Special (non-compliance)

Sample Collection Date:      

mm/dd/yyyy

Sample Collection Time:      

hh:mm am/pm

Pb/CuStreet Address or Tap Location:      

Lead/Copper Location Type:

(At Source, Flushed, First Draw, Lead Service Line)

Data Quality Results:

Analysis: -- Accepted

-- Rejected

--Invalid Sampling Point

--Broken

--Chlorine Present

--Exceeds Holding Time

--Frozen Sample

--Excessive Head Space

--Insufficient Sample Information

--Invalid Sampling Protocol

--Lab Accident

--Leaked in Transit

--Insufficient Volume

Sample Results:

Analyte |Analyte Code |Method Code |Results Sign |Results Value |Results Units |Analytical Lab ID# |Analyst # |Analysis Date |QC Date | |Alpha, total |4002 |      |  |      |pCi/L |      |      |      |      | |Radium-228 |4030 |      |  |      |pCi/L |      |      |      |      | |Radium-226 |4020 |      |  |      |pCi/L |      |      |      |      | |Uranium, total |4006 |      |  |      |pCi/L |      |      |      |      | |Alpha, dissolved |4040 |      |  |      |pCi/L |      |      |      |      | |Alpha, suspended |4041 |      |  |      |pCi/L |      |      |      |      | |Barium-140 |4278 |      |  |      |pCi/L |      |      |      |      | |Beta, dissolved |4042 |      |  |      |pCi/L |      |      |      |      | |Beta, suspended |4043 |      |  |      |pCi/L |      |      |      |      | |Beta, total |4100 |      |  |      |pCi/L |      |      |      |      | |Cesium-137 |4276 |      |  |      |pCi/L |      |      |      |      | |Cesium-134 |4270 |      |  |      |pCi/L |      |      |      |      | |Iodine-131 |4264 |      |  |      |pCi/L |      |      |      |      | |Potassium-40 |4044 |      |  |      |pCi/L |      |      |      |      | |Radium, total |4010 |      |  |      |pCi/L |      |      |      |      | |Radon-222 |4004 |      |  |      |pCi/L |      |      |      |      | |Strontium-89 |4172 |      |  |      |pCi/L |      |      |      |      | |Strontium-90 |4174 |      |  |      |pCi/L |      |      |      |      | |Tritium |4102 |      |  |      |pCi/L |      |      |      |      | |Uranium-234 |4007 |      |  |      |pCi/L |      |      |      |      | |Uranium-235 |4008 |      |  |      |pCi/L |      |      |      |      | |Uranium-238 |4009 |      |  |      |pCi/L |      |      |      |      | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |

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