Free New Nitrate eForm (ICPR Format) - Indiana

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NITRATE & NITRITE IN DRINKING WATER
State Form 53281 (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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.

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System Contact Phone No:

PWSID:

Public Water System Name:

I N
Public Water System Contact Person:

Main Lab Certification: Main/Contracted Laboratory Name: Lab Contact Person: Contact Phone No:

-

Testing Lab ID:

Sample ID: POE: SamplingSite/Location:

C .

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Collection Date (MM/DD/YY):

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Comp ID# Compound Name

Analysis Date (MM.DD.YY)

Approved Method **

Result (mg/L)

Detection Level

BDL

MCL (mg/L)

1040 1041 1038

Nitrate Nitrite Nitrite & Nitrate

. . .

. . .

. . .

. . .

1 0. 0 1. 0 1 0. 0

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

Yes Yes Yes

No No No

Preservative Used: Iced H2SO4 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: