TWISS ANALYTICAL LABORATORIES, INC
DRINKING WATER SAMPLE INFORMATION (WSI) FOR
INORGANIC CHEMICAL ANALYSIS
See Sampling Instructions on back of page
2. System Name:
1. System ID No:
3. Group (circle)
A
4. Sample Location:
5. Date/Time Collected:
6. Sample Collected By:
AM/PM
B
Private
Lab Number: Lab use only
7. Sampler Phone Number:
8. Sample Type: (Circle one)
Untreated (raw)
Treated
9. County: (circle one)
10. Sample Purpose:
11. SampleComposition
Kitsap
Clallam
Jefferson
Routine Compliance
Single Source
Mason
Pierce
Thurston
Confirmation
Blended
Island
King
Grays Harbor
Investigative
Composite
Other:
Other
Distribution
13. Send Report To: (Print Name, Address, Zip Code) 14. Phone No.:
Unknown
12. Source No (s):
___ ___, ___ ___,
___ ___, ___ ___,
___ ___, ___ ___,
___ ___, ___ ___
15. Fax No.:
16. Email:
17. Special Instructions:
Analysis
Requested
 Group A IOC (complete)
(Sb,As,Ba,Be,Cd,Cr,CN-,F,Hg,Ni,Se,Tl,
NO3-N,NO2-N,Cl,Fe,Mn,Ag,SO4,Zn,Na,
hard,cond,turb,color, Pb,Cu)
Check a
group
 Group B IOC (complete)
or circle
(same as Group A minus Pb, Cu)
individual
tests below
 Nitrate only
EPA
EPA REGULATED
REGULATED
 Kitsap 5 (NO3-N, Fe, Mn Cl-,Cond)
 Pierce County IOC
(Sb,As,Ba,Be,Cd,Cr,CN,F,Hg,Ni,Se,Tl,
NO3.-N,NO2-N,Fe,Mn,Na, turb,Pb,Cu)
 Jefferson County (NO3-N, Cl-)
EPA REGULATED
(Secondary)
 Primary IOC
(Sb,As,Ba,Be,Cd,Cr,CN,F,
Hg,Ni,Se,Tl,NO3-N, NO2-N,
Na,Turb,Pb,Cu)
 Other (circle individual
test or write in new test
below)
STATE
REGULATED
UNREGULATED
Antimony (Sb)
Nitrate-N (NO3-N)
Chloride (Cl-)
Sodium (Na)
Alkalinity
Arsenic (As)
Nitrite-N (NO2-N)
Iron (Fe)
Hardness
Calcium (Ca)
Barium (Ba)
Total Nitrate/Nitrite
Manganese (Mn)
Conductivity
Magnesium (Mg)
Beryllium (Be)
Nickel (Ni)
Silver (Ag)
Turbidity
Potassium (K)
Cadmium (Cd)
Selenium (Se)
Sulfate (SO4-2)
Chromium (Cr)
Thallium (Tl)
Zinc (Zn)
Color
Other: (list)
pH
Chlorine Residual (circle)
Free and/or Total
Orthophosphate-P
(PO4-P)
Sulfide (H2S)
Tannin
Fluoride (F-)
Lead (Pb)
Total Organic Carbon
(TOC)
Total Dissolved Solids
Mercury (Hg)
Copper (Cu)
Bromate (BrO3-)
Cyanide (CN-)
STATE
UNREGULATED
Sample
Relinquished By:
Date /Time:
Condition on Receipt:
Sample Received
By:
Date /Time:
Temperature On Receipt:
26276 Twelve Trees Lane, Suite C  Poulsbo, WA 98370 (360) 779-5141  Fax: (360) 779-5150  www.Twisslabs.com
D:\116100555.doc
Revision date 02/08/13
TWISS ANALYTICAL LABORATORIES, INC
SAMPLING INSTRUCTIONS FOR INORGANIC
CHEMICAL (IOC) ANALYSIS OF DRINKING WATER SAMPLES
PUBLIC SYSTEM SAMPLING INSTRUCTIONS
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The sample should be taken as close to the source as possible, after treatment and before distribution.
Disconnect any garden hose or appliance that may be connected to the spigot.
From the spigot or tap, run the water 2 to 3 minutes before taking the sample.
If you have a sample container that is the 1 liter collapsible type, before taking the sample, inflate the
container by gently blowing into the bottle. Only ONE container is needed if requesting less than 10
parameters . TWO containers of sample (2 liters) are necessary for a COMPLETE Group A,
Group B, Pierce County IOC or Primary. If Color is requested, also fill a 125 ml brown plastic
bottle. Fill the sample container(s) to the very top.
Bottles must be labeled with location of sample, date and time collected, and analysis requested. All
samples must be kept cold after sampling and during transport.
Fill in boxes 1 through 16 using ink.
Deliver the sample and form to the laboratory within 24 hours of sampling.
PRIVATE SYSTEM SAMPLING INSTRUCTIONS








Disconnect any garden hose or appliance that may be connected to the spigot.
From the spigot or tap, run the water 2 to 3 minutes before taking the sample.
If you have a sample container that is the 1 liter collapsible type, before taking the sample, inflate the
container by gently blowing into the bottle. Only ONE container is needed if requesting less than 10
parameters . TWO containers of sample (2 liters) are necessary for a COMPLETE Group A,
Group B, Pierce County IOC or Primary. If Color is requested, also fill a 125 ml brown plastic
bottle.
Fill the sample container(s) to the very top.
Bottles must be labeled with location of sample, date and time collected, and analysis requested.
All samples must be kept cold after sampling and during transport.
Fill in the following boxes using ink: 2 -9, 13-14 (other fields are optional)
Deliver the sample and form to the laboratory within 24 hours of sampling.
PRIVATE SYSTEM LEAD AND COPPER SAMPLING INSTRUCTIONS

The sample must be collected from a cold water faucet inside the home. There must be a six-hour
period (but no more than a twelve-hour period) during which there is no water use throughout
the residence prior to sampling. The object is to get the “first draw” of the water that has sat stagnant
in the line. Do not sample from faucets that are connected to any type of treatment such as water
softeners or filters.
 If you have a sample container that is the 1 liter collapsible type, before taking the sample, inflate the
container by gently blowing into the bottle. Place the open bottle below the faucet and gently open the
cold water tap. Fill the sample container completely, to the very top (1 liter), and turn the water off..
Tightly cap the container. Any amount other than 1 liter could give erroneous results.
 Bottles must be labeled with client, location of sample, date and time collected, and analysis requested.
26276 Twelve Trees Lane, Suite C  Poulsbo, WA 98370  (360) 779-5141  Fax: (360) 779-5150  www.Twisslabs.com
D:\116100555.doc
Revision date 02/08/13