Free New WQP eForm (ICPR Format) (32 - Indiana

Page 1 of 1

WATER QUALITY PARAMETERS AND SOURCE WATER REPORTING
State Form 53292 (6-07)

Reset Form

W QP

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

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

PWSID:

Public Water System Name:

I N
Public Water System Contact Person: Contact Phone Number:

Point-of-Entry (POE):
Certified Lab ID: Certified Laboratory Name:

Lab Contact Person: Contact Phone Number :

-

C /
Location # (2 Sets/each)

Lab Report Number: Lab Received Date (MM/DD/YY):

Lead & Copper Action Level Exceedance Date (MM/DD/YY):

Temperature Orthophosphate (oC) or Silicate (if added)

/
Sample Date (MM/DD/YY)

/
Sample Location (Decribe briefly) Lab Sample ID Calcium (mg/L)

/
Conductivity (umhos/cm)

Number of Distribution Sites required:
pH Alkalinity (mg/L)

Distribution Sites

#1 - Set 1 #1 - Set 2 #2 - Set 1 #2 - Set 2 #3 - Set 1 #3 - Set 2 #1 - Set 1 #1 - Set 2 #2 - Set 1 #2 - Set 2

. . . . . . . . . .

. . . . . . . . . .

. . . . . . . . . .
Source Water Lead & Copper Results (@POE in mg/L):

. . . . . . . . . .
Lead

. . . . . . . . . . .

. . . . . . . . . .
Copper

. . . . . . . . . .

. . . . . . . . . .

Point-of-Entry

.

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