179 Neb. Admin. Code, ch. 25, Attachment 1
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)
179 Neb. Admin. Code, ch. 25, Attachment 1