Form Eqp 2300 PDF Details

The EQP 2300 form is a crucial document utilized by the Department of Environmental Quality in Lansing, Michigan, for individuals or entities requesting water analysis tests. This comprehensive form serves multiple purposes, including capturing billing information and detailing the specific tests required for drinking water or pool/spa analysis, among others. It mandates prepayment or the provision of an approved DWL credit account number to carry out the testing, emphasizing the need for financial readiness before submission. The form is structured to gather essential details about the sample source and purpose, ranging from routine monitoring to identifying water quality problems, with clear instructions on sample collection to ensure accuracy and reliability of the test results. Additionally, the EQP 2300 form delineates fee amounts for various tests, which are subject to annual review and adjustment, and it requires precise information about the sample collection process, including the collector's details, the collection site, and the date and time the sample was taken. Furthermore, it outlines careful instructions on how to properly collect and submit samples, ensuring they meet the standards for analysis. This detailed approach to sample submission underlines the importance of accuracy and completeness in environmental testing, helping to safeguard public health through rigorous water quality assessments.

QuestionAnswer
Form NameForm Eqp 2300
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesEQP, 2011, DEQ, 36VO

Form Preview Example

Billing inFORMATiOn PLEASE PRINT

Name

DWl Account number

 

 

 

 

Mailing Address

 

 

 

 

 

 

 

City

 

State

Zip

 

 

 

 

Check#, if applicable (pay to State of Michigan)

 

Amount enclosed

 

 

 

 

DRINKING WATER LABORATORY - lAnSing

DEPARTMENT OF ENVIRONMENTAL QUALITY

REQUEST FOR WATER AnAlYSiS

FEE AMOUnTS On THiS FORM ARE EFFECTivE JAn. 1, 2010. Fee amounts are subject to annual changes.

Sample Collection Instructions are on the back of this form

PREPAYMEnT OR APPROVED DWl CREDiT ACCOUnT nUMBER iS REQUiRED FOR TESTing.

WSSN (Type I-II Public Water) or Pool Serial Number

 

 

 

 

 

 

DO nOT SEnD CASH!

 

 

 

Does sample contain chlorine?

Yes

No

 

 

 

 

 

 

 

SAMPlE SOURCE - CIRCLE ONE

SAMPling PURPOSE - CIRCLE ONE

 

0

-

Single Family Dwelling

0 - Routine Monitoring

 

3 - Repair/Construction/New Well

 

 

 

 

 

1

-

TYPE I (community, apartment, subdivision, mobile home

1 - Real Estate Transaction

5 - Water Quality Problem

 

 

park, etc., with 25 or more residents year round)

2 - Repeat Sample

 

9 - Other

2

-

TYPE II (school, industry, restaurant, ofice, etc., serving 25 or

 

 

 

 

 

 

 

 

more persons - 60 days or more per year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

-

TYPE III (all other public supplies, duplex, small ofice, etc.)

SAMPlE POinT - CIRCLE ONE

 

 

5 - Untreated Private Well

7

-

Surface Water (includes bathing beach and wastewater dis-

1- Public System Well

 

 

 

 

 

 

 

 

 

 

 

charge)

2- Public System Surface Water

 

 

6 - Treated/Softened Private

8

- Swimming pool or Spa

3- Untreated Public Distribution System

Well

 

 

 

 

 

 

7 - Pressure Tank/Plant Tap

9

-

Other

4- Treated Public Distribution System

 

 

 

 

 

 

9 - Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SEnDER inFORMATiOn PLEASE PRINT nOTE: RESUlTS Will BE AUTOMATiCAllY COPiED TO lOCAl COUnTY HEAlTH DEPARTMEnT

Name

E-mail address

Mailing Address

Area Code & Phone number

City

State

ZIP Code

SAMPlE COllECTiOn inFORMATiOn PLEASE PRINT

Sample Collector Name

 

 

 

Date Collected

 

 

 

Time Collected

 

 

 

Circle One

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

Do nOT analyze my sample(s) if received past the EPA speciied hold time. (Hold times are indicated on the sample bottle.)

 

 

 

 

 

 

THE DATE AnD TiME COllECTED MUST BE FillED OUT!

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Analyze my sample(s) even if received beyond the EPA speciied hold time.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

nOTE: If a selection is not made, your sample(s) will be analyzed. Although samples analyzed beyond hold time typically

 

 

 

 

cannot be used for compliance purposes, the results may still have informational value.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Collector Code

0 - County Personnel

1- Water Supply Operator

2- DEQ DW staff 3- Private Citizen

System/Owner name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CIRCLE ONE

4 - DEQ Staff other than DW 6- MDA Staff

9- Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Collection Site (Street Address)

 

 

 

 

 

Township (If known)

 

 

Section (If known)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

County

 

ZIP Code

 

 

 

 

 

Well

(If more than one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sampling Point (kitchen, bath, etc.)

 

 

 

 

 

Site Code or Permit Number (If known)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TESTing REQUEST inFORMATiOn (REQUiRED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

inSTRUCTiOnS:

 

 

 

 

 

 

 

 

 

TEST

 

REQUIRED

 

DRInkIng waTER oR pool/Spa

 

 

analysis.Check box next to Test Code(s) of desired

 

 

CODE

 

UNIT #

 

 

TEST

fEE

 

 

B

 

30

 

Water Coliforms (Bacteriology)

$16.00

 

 

 

 

 

 

Check the UNIT# on bottle to ensure you have

 

 

 

 

 

 

 

30 hour hold time

 

 

 

 

 

 

the REQUIRED UNIT for desired analysis.

 

 

R

 

32

 

Automated Partial Chemistry,

$18.00

 

 

 

 

 

 

 

For other types of testing, enter the TEST

 

 

 

 

 

 

 

including Fluoride, Chloride, Hardness,

 

 

 

 

CODE, UNIT# (located on the sample bottle)

 

 

 

 

 

 

 

Nitrate, Nitrite, Sulfate, Sodium and Iron

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

and FEE in the area on the right side of this

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CAS

 

36ME

 

Arsenic

 

 

$18.00

 

 

section.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Refer to the full Testing Fee Schedule available

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CPB

 

36ME

 

Lead

 

 

$18.00

 

 

from county health departments and DEQ Drink-

 

 

 

 

 

 

 

 

ing Water Laboratory for other types of testing.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fee amounts are subject to annual changes.

 

 

CCUB

 

36CC

 

Lead/Copper for corrosion control

$26.00

 

 

 

 

 

 

 

 

 

 

 

 

 

CXVO

 

36VO

 

Volatile Organic Compounds

$100.00

 

 

TEST CODE

UniT#

 

FEE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TEST

 

REQUIRED

 

SURfacE oR waSTEwaTER TEST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CODE

 

UNIT #

 

(Pond, lake, Ditch, etc.)

fEE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPEC-LO

 

30

 

E. coli (Counts 10 - 10,000)

$15.00

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

delivery to lab-6 hours

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPEC-HI

 

30

 

E. coli (Counts 10 - 1,000,000)

$25.00

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

delivery to lab-6 hours

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPFC-LO

 

30

 

Fecal Coliform (Counts 10 - 10,000)

$15.00

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

delivery to lab-6 hours

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTAl OF All FEES

 

 

 

 

 

 

NPFC-HI

 

30

 

Fecal Coliform (Counts 10 - 1,000,000)

$25.00

 

 

 

 

 

 

 

 

 

 

 

 

 

delivery to lab-6 hours

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EQP 2300 (Front) 12/2011)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Submit White Copy With Sample - Keep Yellow Copy For Your Records

A form is required for each sample site (Collection Site, Sampling Point, and Date/Time must be the same for all samples with this form).

Complete all parts of this form which apply. Samples not properly identiied or not having clear test requests MAY NOT be tested.

Fill in your email address, if you would like a copy of the report emailed when completed.

For additional information contact your local county health department or the Drinking Water laboratory, (517) 335-8184 or visit our web site: http://www.michigan.gov/deq

Allow two weeks for results on most testing.

SAMPlE COllECTiOn inSTRUCTiOnS

UniT# inSTRUCTiOnS

301. This testing unit contains preservatives in the sample bottle. Do not rinse the bottle with sample. Do not open the bottle until ready to collect the sample. Do not touch the inside of cap or bottle.

2.If not collecting sample from a tap (lake, pool, etc.), plunge bottle mouth down, move in continuous arc down and back up from water, discard top half-inch or to 100 ml line.

3.If using a sample tap, select a clean (disinfect as necessary) faucet and remove such attachments as aerators, dishwasher connectors, etc. Allow water to run for about ten minutes at full low from the sampling tap. Reduce low to avoid splashing, and collect the sample directly into the bottle. Do not use an intermediate container. Do not allow water from the outside surface of the faucet to drip into the bottle. Fill bottle only to the bottom of neck, or to 100 ml line.

4.Most bacteriological testing has a 30 hour EPA hold time. Samples must be received at the laboratory before the hold time expires. Surface water samples must be received at the laboratory within 6 hours of sampling.

32*, 33*

1.

Sample bottle may contain preservative (refer to unit label on bottle). Do not rinse bottle with

36AC

 

sample. Do not open the bottle until ready to collect the sample. Do not touch the inside of cap or

36Cn, 36HA*

 

bottle.

36HB, 36lP 2.

Select a clean faucet and remove such attachments as aerators, dishwasher connectors, etc. Allow

36ME, 36PT

 

water to run for about ten minutes at full low from the sampling tap. Reduce low to avoid splashing,

and collect the sample directly into the bottle. Do not use an intermediate container. Do not allow water from the outside surface of the faucet to drip into the bottle. Fill bottle to the bottom of neck.

36TO*

36vO* 36vO-nP*

1.The sample vials contain preservative. Tap each vial in upright position to drain preservatives from cap. Do not rinse vial before collection.

2.Do not open the vial until ready to collect the sample. Do not touch the inside of cap or vial. Select a clean faucet without attachments or leaking stem. Allow water to run for ten minutes at full low.

3.Reduce low and collect the sample directly into all vials provided.

a.For 36TO, ill vial until water rounds at the top of vial.

b.For 36vO, ill vial HALFWAY. Add 2-3 drops of the provided acid from small dropper bottle. Com- pletely ill vial until water rounds at the top of vial.

4.Cap and invert to check for air in vial. THE SEPTA (RUBBER PART INSIDE CAP RING) MUST BE SMOOTH SIDE DOWN IN CONTACT WITH SAMPLE TO AVOID POSSIBLE CONTAMINATION.

5.If air is observed in inverted sample, remove cap, add water (DOn’T DUMP SAMPlE) and recap as instructed.

36Cna

1.

Enclosed vial contains dilute preservative and caution should be exercised. This testing

 

unit also contains preservatives in the sample bottle. Tap unit in upright position to drain

 

 

 

 

preservatives from cap. Do not rinse bottle before collection.

 

2.

Do not open the bottle until ready to collect the sample. Do not touch the inside of cap or bottle.

 

3.

Do not rinse the bottle with sample. Select a clean faucet without attachments or leaking stem. Allow

 

 

water to run for about ten minutes at full low from the sampling tap.

 

4.

Reduce low to avoid splashing, and collect the sample directly into the bottle. Do not use an

 

 

intermediate container. Fill to 1" below top of bottle. Cap and invert 5 times to mix sample with

 

 

preservatives. Carefully add all preservative in vial to sample bottle. Cap the sample and mix

 

 

sample. Rinse vial and return.

 

 

 

36CC

1.

Do not open the bottle until ready to collect the sample. Do not touch the inside of cap or bottle.

2.Select a kitchen or bathroom sink or a faucet from which water is typically drawn for consumption.

Sampling point should not have been used for a minimum of six (6) hours prior to sampling.

Do not lush the sample tap before sample collection.

3.Samples must be received in the laboratory within 14 days of collection.

* nOTE: Some tests require thermal preservation. If you received your kit with an ice pack, please ensure that the ice pack is frozen prior to return shipment to the laboratory.

EQP 2300 (Back) 12/2011

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Best ways to prepare 36CC step 1

2. The next part is to fill out these blanks: REPORT RESULTS TO Name, Address, Send Report to Email, BILLING INFORMATION, Check here if billing nameaddress, Billing Address, Phone Number, City, Billing Name, City, State, Zip, State, Zip, and EGLE Drinking Water Lab Acct.

BILLING INFORMATION, Billing Address, and Zip of 36CC

3. Completing CPB CXVO CXTM CXHA CXPT CXHB CXLP, VO VO HA PT HB LP, Disinfection Byproducts Rule TTHM, Enter additional test, code sample container and fee from, Schedule here, See reverse side for sample, FOR LAB USE ONLY, Sample Receipt Temperature, Received on Ice within hours, Yes, ºC No, EQP, Total of all fees, and Submit White Copy With Sample is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

See reverse side for sample, EQP, and Yes of 36CC

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