Free New TOC eForm (ICPR Format) (48 - Indiana

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MONTHLY TOTAL ORGANIC CARBON REMOVAL REPORTING
State Form 53284 (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 PWSID: Plant Num: System 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.

Plant Name:

Monitoring Period (MM/DD/YYYY):

Please submit completed form to: IDEM - OWQ Drinking Water - MC 66-34 100 N Senate Avenue Indianapolis, IN 46204-2251

/ 01 / 20

Testing Lab Certification:

Laboratory Name:

C .

Lab Contact Person: Contact Phone No:

Collection Date (MM/DD/YY):

.
Sample ID:

TOC Analytical Method:

5310C 5310D

5310B
These are your tests results:

And these are calculated/obtained results:

(A) Treated Water TOC:

. . .

mg/L

(C) Achieved TOC Removal: = [1-(A)/(B)]*100

.

%

(B) Source Water TOC:

mg/L

(E) Required TOC Removal: (From Matrix Below)

.0 % .

(D) Source Water Alkalinity:

mg/L

(C/E) Ratio: (Divide C by E Above)

Step 1 TOC Table: Required TOC Removal Matrix
Source Water TOC (mg/L) Source Water Alkalinity, mg/L, as Ca CO3

0-60 35.0% 45.0% 50.0%

>60-120 25.0% 35.0% 40.0%

>120 15.0% 25.0% 30.0%

>2.0 to 4.0 >4.0 to 8.0 >8.0
Notes:

- At least one set of "paired" TOC samples and one source water alkalinity sample must be collected each month. - The first of these "paired" samples must be collected from the source water prior to any treatment. - The alkalinity sample must be collected simultaneously and from the same location that the source water TOC sample is collected. - Compliance is determined based on a four-quarter running annual average of monthly samples averaged quarterly, as applicable. - All the samples collected and analyzed shall be included in determining compliance, even if the number of samples exceeds the minimum number of samples required. - The use of a certified laboratory is not required for TOC analysis, but a state-approved method must be used (e.g., Method 5310).

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