Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 179 - PUBLIC WATER SYSTEMS
Chapter 25 - LONG TERM 2 (LT2) ENHANCED SURFACE WATER TREATMENT
Attachment 179-25-1 - Sampling Training For Individuals Other Than Licensed Operators

PWS System or Community Name: _________________________________________

Name of individuals taking samples:_________________________________________

Parameter(s) sampled routinely by the above individual:

______________________________________________________________________

Trainer and Title: ________________________________________________________

Training material used: ___________________________________________________

Handouts given to the above individual:

______________________________________________________________________

I certify that on ________________ I personally provided the necessary sampling

(Date)

training to assure quality data and approve the above individual as qualified to perform the above sampling tasks.

X____________________________________________________________________

(Signature of Trainer) (License Number)

I certify that I did receive said training and I understand how to properly sample the above parameters.

X____________________________________________________________________

(Signature of Approved Sampling Individual)

When the above-named trained person no longer takes the samples the individual has been trained to take, I will inform the Nebraska Department of Health and Human Services, Drinking Water Program Field Services Program Manager at (402) 471-0521 within seven days. Acknowledged by System Owner or Operator in Charge:

X____________________________________________ Date: ___________________

(Signature)

(Keep a copy for your records and submit original within seven days to DHHS, Division of Public Health, Public Water Program at P. O. Box 95026, Lincoln, NE 68526-5026)