Free New VOC eForm (ICPR Format) (34 - Indiana

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VOLATILE ORGANIC COMPOUNDS (VOC's) IN DRINKING WATER
State Form 53286 (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:

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Main Lab Certification: Main/Contracted Laboratory Name:

Testing Lab ID:

Lab Contact Person: Contact Phone No:

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Comp ID#

Sample ID: POE: SamplingSite/Location:

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Collection Date (MM/DD/YY):

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Compound Name
Benzene Carbon Tetrachloride Chlorobenzene 1,2-Dichlorobenzene 1,4-Dichlorobenzene 1,2-Dichloroethane 1,1-Dichloroethylene

Analysis Date (MM.DD.YY)

2990 2982 2989

VOCs

2968 2969 2980 2977

Regulated

2 9 7 2 1,2-Dichloroethylene, cis Tetrachloride 2 9 7 9 1,2-Dichloroethylene, trans 2964 2983 2992 2996 2987 2991 2378 2981 2985 2984 2976 2955
Dichloromethane 1,2-Dichloropropane Ethylbenzene Styrene Tetrachloroethylene Toluene 1,2,4-Trichlorobenzene 1,1,1-Trichloroethane 1,1,2-richloroethane Trichloroethylene Vinyl Chloride Total Xylenes

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Approved Method ** 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2

Result (ug/L)

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Unit Detection BDL (ug/L) Level ug/L 0.5 ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L

MCL (ug/L)

5 5 100 600 75 5 7 70 100 5 5 700 100 5 1 000 70 200 5 5 2 1 0000

0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5

** See important note on reverse (page 2) if an alternate method was used.

PWSID:

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Collection Date (MM/DD/YY):

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Comp ID#

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Bromobenzene Bromomethane Chloroethane Chloromethane 2-Chlorotoluene 4-Chlorotoluene

Unregulated
Analysis Date (MM.DD.YY) Approved Method 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2 524.2

VOCs
Result (ug/L) Unit Detection BDL (ug/L) Level ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L

Compound Name

2993 2214 2216 2210 2965 2956 2967 2978 2412 2416 2410 2413 2986 2988 2414 2408 2943 2942 2944 2941 2251

1,3-Dichlorobenzene 1,1-Dichloroethane 1,3-Dichloropropane 2,2-Dichloropropane 1,1-Dichloropropene 1,3-Dichloropropene (cis & trans) 1,1,1,2-Tetrachloroethane 1,1,2,2-Tetrachloroethane 1,2,3-Trichloropropane Dibromomethane Bromodichloromethane Bromoform Chlorodibromomethane Chloroform Methy-Tert-Butyl Ether (MTBE)

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Yes Yes Yes

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

No No No

Preservative Used: Iced Na2S2O3 HCl Ascorbic Acid Other:

Completed By: Important Notes:

Reviewed by:

Alternate Method: - if an alternate approved method (example, 502.2) was used for the analysis, please indicate the alternate method used here: - if a constituent was below detection limits (i.e., not detected), select "BDL" and enter the method detection level (example: 0.5 ug/L) in the column provided. - Please make every possible effort to print clearly and inside the lines; - Return completed form to: Indiana Department of Environental Management Drinking Water Branch - Compliance Section 100 N Senate Avenue Indianapolis, IN 46204-2251