Sample Container Requisition Form Client Name: Date Submitted / By: / Contact: Address: Date Due: Telephone: Labels Needed? Yes or No (circle one) Project Name: Trip Blanks Needed? Yes or No (circle one) Sampling Date: Explain: ________________________________________________________ Delivery: Ship Drop-off Pick-up (circle one) Special Explain: ________________________________________________________ Instructions: Date Completed / By: / Quantity Container Type Preservative Analyses Required PLASTIC 120 mL Sterile Poly [PC] w/ White Cap Na2S2O3 tablet Micro:_________________________ 120 mL Sterile Poly [PE] w/ Flip Top, No Label Na2S2O3 tablet Micro:_________________________ 120 mL Poly, Wide Mouth [HDPE] EDA Bromate, Chlorate, Chlorite 120 mL Poly, Wide Mouth [HDPE] NaOH + ZnAc Sulfide 120 mL Poly, Wide Mouth [HDPE] -none- 250 mL Poly, Wide Mouth [HDPE] HNO3 Metals:_______________________ 250 mL Poly, Wide Mouth [HDPE] -none- 500 mL Poly, Wide Mouth [HDPE] HNO3 Hg, Metals:____________________ 500 mL Poly, Wide Mouth [HDPE] -none- 1 Liter Poly, Wide Mouth [HDPE] 1 Liter Poly, Wide Mouth [HDPE] -none- "First Draw" Pb & Cu 1 Gallon Poly [HDPE] -none- Aquatic Toxicity GLASS 40 mL Vial, Silicone Septa Top 1:1 HCl GRO, VOCs:___________________ 40 mL Vial, Silicone Septa Top, Preweighed MeOH GRO, VOCs:___________________ Syringe, 10 mL, flush cut 40 mL Vial, Silicone Septa Top AA Drinking Water VOCs, THMs Dropper, 4 mL, 1:1 HCl solution 40 mL Vial, Silicone Septa Top -none- 40 mL Amber Vial, Silicone Septa Top Na2S2O3 + PDC SOC Carbamates 40 mL Amber Vial, Silicone Septa Top Na2S2O3 Geosmin/MIB, EDB/DBCP 40 mL Amber Vial, Silicone Septa Top -none- Geosmin/MIB (not chlorinated) 250 mL Amber Glass NH4Cl HAA5 250 mL Amber Glass Na2SO3 SOC Herbicides 250 mL Amber Glass H2SO4 250 mL Amber Glass NaOH 1 Liter Clear Glass, Wide Mouth 1:1 HCl FOG / HEM 1 Liter Clear Glass, Wide Mouth -none- 1 Liter Amber Glass Na2SO3 SOC Pesticides 1 Liter Amber Glass -none- SVOCs, PNAs, PCBs, Pesticides 8 oz. Clear Glass, Boston Round NaOH Dissolved Sulfide Dropper, 4 mL, AlCl3 solution 4 oz. Jar -none- 8 oz. Jar -none- 16 oz. Jar -none- GLASS or METAL (for Fuels) 32 oz. Amber Glass, Boston Round Polycone Seal 32 oz. Clear Glass, Boston Round Polycone Seal 1 Gallon Steel Can & Cap Metal Seal FORM-N0008A, Revision 6, Effective Date 02/11/14, Page 1 of 2 Copyright © 2002-2014 by Paragon Laboratories, Inc. All rights reserved. Sample Container Requisition Form Preservative Key Abbrev. Preservative, Concentration Goal Amount to Add AA: Ascorbic Acid, powdered dechlorinate 25 mg / 40-mL vial AlCl3: Aluminum Chloride, 38% solution flocculation 0.50 mL (10 drops) / 250-mL bottle EDA Ethylenediamine, 1% solution preserve 0.60 mL / 120-mL bottle Filter: Filter (0.45µm) preferably on-site remove particulate HCl: Hydrochloric Acid, 1:1 HCl:PDI solution attain pH <2 2 drops to 0.5 ml 1:1 HCL / 40-mL vial, or ~6 to 8 mL / 1-L bottle HNO3: Nitric Acid, Conc. attain pH <2 2.5 mL / 250-mL bottle H2SO4: Sulfuric Acid, Conc. attain pH <2 0.50 mL / 250-mL bottle MeOH: Methanol, Trace P&T Grade extract 10 mL / 40-mL vial, preweighed NaOH: Sodium Hydroxide, 5N solution attain pH >9 0.25 mL / 250-mL bottle Sodium Hydroxide, 5N solution attain pH >12 0.50 mL / 250-mL bottle NaOm Sodium Omadine, 3.2% solution preserve 80 µL / 40-mL vial Na2SO3: Sodium Sulfite, granular dechlorinate 12.5 mg / 250-mL bottle Na2S2O3: Sodium Thiosulfate, granular dechlorinate 3 to 5 mg / 40 mL vial, or 1 tablet (~10 mg) / 120-mL bottle NH4Cl: Ammonium Chloride, granular chlorine conversion 25 mg / 250-mL bottle PbCO3: Lead Carbonate, powdered stabilize 0.25 g / 250-mL bottle PDC: Potassium Dihydrogen Citrate, granular stabilize 375 mg / 40 mL vial PDI: Polished Deionized (DI) Reagent Water diluting ZnAc: Zinc Acetate, 2M solution stabilize 0.25 mL (5 drops) / 120-mL bottle Volume Equivalents Ounces Milliliters (Bottle Equivalent [≡]) 4 118 mL ( ≡ 120-mL bottle) 8 237 mL ( ≡ 250-mL bottle) 16 473 mL ( ≡ 500-mL bottle) 32 946 mL ( ≡ 1-L bottle) FORM-N0008A, Revision 6, Effective Date 02/11/14, Page 2 of 2 Copyright © 2002-2014 by Paragon Laboratories, Inc. All rights reserved..