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PUBLIC WATER SYSTEM INFORMATION: PWS ID: OH PWS Name: STU ID: STU Name: Address: City, State, Zip: County: SAMPLE INFORMATION: Sample Monitoring Point Sample Type: -- Routine (compliance) -- Special (non-compliance) Sample Collection Date: mm/dd/yyyy Sample Collection Time: hh:mm am/pm LABORATORY INFORMATION: Reporting Lab Name: Reporting Lab Certification No.: Lab Sample Number: Comments Street Address or Tap Location: Lead/Copper Location Type (At Source, Flushed, Fi.

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