Free New Bromate eForm (ICPR Format) - Indiana

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MONTHLY BROMATE REPORTING
State Form 53290 (6-07)

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

INSTRUCTIONS: This form is only required for Systems Using Ozone as part of their Water Treatment Process.

PWSID:

Plant Number: System Name: Plant Name:

I N
This form must be completed and submitted to IDEM within the first ten (10) days after the end of the monitoring period in which the samples were collected.

Monitoring Period (MM/DD/YYYY):

Please submit completed form to: IDEM - Drinking Water Branch 100 N Senate Avenue Indianapolis, IN 46204-2251

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Testing Lab Certification:

Laboratory Name:

C .

Lab Contact Person: Sample ID: Contact Phone Number:

Collection Date (MM/DD/YY):

.
Bromate Method:

300.1 300.1

Bromide Method:

300.0

If a result was detected, enter the result in the left box, otherwise check the BDL box and enter the detection level in the field provided. Please note that Bromide is an optional analysis for systems considering requesting reduced Bromate monitoring.

Bromate Result:

.

ug/L

or

Below Detection Level (BDL):
Detection Level:

.

ug/L

Bromide Result:

.

ug/L

(Optional)

or

Below Detection Level (BDL):
Detection Level:

.

ug/L

Notes: - CWSs and NTNCWSs using ozone for disinfection or oxidation shall take one (1) sample per month for each treatment plant using ozone. - Systems shall take monthly samples at the entrance to the distribution system while the ozonation system is operating under normal conditions. - Systems required to analyze for bromate may reduce monitoring from monthly to once per quarter, if the system demonstrates that the average source water bromide concentration is less than five-hundredths (0.05) milligram per liter based upon representative monthly bromide samples' measurements for one (1) entire year. - The system may remain on reduced bromate monitoring as long as their running annual average source water bromide concentration, computed quarterly, is less than five-hundredths (0.05) milligram per liter based upon representative monthly measurements. - If the running annual average source water bromide concentration is equal to or greater than five-hundredths (0.05) milligram per liter, the system shall resume routine monitoring. - The use of a certified laboratory is required for the analysis of Bromate; only EPA Method 300.1 is approved for the analysis of Bromate. - The use of a certified laboratory is required for the analysis of Bromide; only EPA Methods 300.0 and 300.1 are approved for Bromide. - Compliance is determined based on a four-quarter running annual average of monthly samples averaged quarterly, as applicable.

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