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INORGANIC CHEMICALS (IOC's) IN DRINKING WATER
State Form 53285 (6-07)

Indiana Department of Environmental Management (IDEM) Office of Water Quality - Drinking Water Branch - Compliance Section

INSTRUCTIONS: Please submit completed forms to: IDEM OWQ Drinking Water, Mail Code 66-34, 100 N Senate Ave, Indianapolis, IN 46204-2251

Lab Received: For Laboratory Use Only =>
(Write dates as MM/DD/YY)

QA Review Date:

Report Date:

Lab Report Number:

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PWSID:

System Name:

I N
Main Lab Certification: Main/Contracted Laboratory Name:

Testing Lab ID:

Lab Contact Person: Contact Phone No:

C .
1074 1005 1010 1075 1015 1020 1024 1025 1025 1035 1036 1045 1085 1094 1055 1052

Sample ID: POE: SamplingSite/Location:

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Collection Date (MM/DD/YY):

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Analysis Date (MM.DD.YY) Approved Method ** Result (mg/L) Detection Level BDL MCL (mg/L)
Antimony Arsenic Barium Beryllium Cadmium Chromium Cyanide (Free) Fluoride (Adjusted) Fluoride (Natural) Mercury Nickel Selenium Thallium Asbestos

Comp ID# Compound Name

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Yes Yes Yes No No No

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IOCs

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0. 006 0. 010 2. 0 0. 004 0. 005 0. 1 0. 2 2. 0 4. 0 0. 002 0. 1 0. 05 0. 002 7 .M F L
( No MCL ) ( No MCL )

Regulated

Sulfate Sodium

Other Information:
Does the system chlorinate its water? Was the sample dechlorinated at the lab? Was this information sent to IDEM by the lab?

Preservative Used: Iced HNO3 NaOH Other:

I hereby certify that all the information submitted herein is true and accurate to the best of my knowledge. Completed By: Date: Reviewed by: