DDW-2024-006633

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*When submitting a sample
taken from a Routine sample site
designated above, you must
include the Point Code
associated with that site on the
laboratory paperwork.
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Monthly Routine Sample Sites (place an X in boxes below):Follow-up/Repeat Sample Sites DDW Assigned # for
Associated Source(s)
Routine Sample Point Description
Address *Point Code Jan Mar Apr Ma、Jun Aug Sep Oct No、De((range or specific addressl rose bib, sink faucet, etc
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Laboratory Name:
Address:
City:
Zip Code:
Phone Number:
Contact Person:
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DDW Source
Source(s) Name: