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SYNTHETIC ORGANIC COMPOUNDS (SOC's) IN DRINKING WATER
State Form 53287 (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
Alachlor (Lasso) Atrazine Benzo(a)pyrene Carbofuran Chlordane (alpha & gamma) 2,4-D Dalapon DBCP Dinoseb 2,3,7,8-TCDD (Dioxin) Diquat Di(2-ethylexyl)adipate Di(2-ethylexyl)phthalate Endothall Endrin Ethylene Dibromide (EDB) Glyphosate (Round-up) Heptachlor Heptachlor Epoxide Hexachlorobenzene Hexachlorocyclopentadiene

Analysis Date (MM.DD.YY)

Approved Method **

Result (ug/L)

Unit ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L

Detection BDL Level

MCL (ug/L)

2051 2050 2306 2046 2959 2105 2031 2931 2041 2063 2032 2035 2039 2033 2005 2946 2034 2065 2067 2274 2042

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2. 3. 0.2 40. 2. 70. 200. 0.2 7. 0.0 3 20. 400. 6. 100. 0.2 0.0 5 700. 0.4 0.2 1. 50.

pg/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

PWSID:

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Collection Date (MM/DD/YY):

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Comp ID#

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Compound Name

Regulated SOCs (Continued)
Analysis Date (MM.DD.YY) Approved Method ** Result (ug/L) Unit ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L ug/L Detection BDL Level MCL (ug/L)

2010 2015 2036 2326 2040 2383 2037

Lindane Methoxychlor Oxamyl (Vydate) Pentachlorophenol Picloram (Tordon) PCBs Simazine

2 1 1 0 2,4,5-TP (Silvex) 2 0 2 0 Toxaphene 2047 2044 2043 2356 2076 2021 2440 2070 2066 2022 2045 2595 2077
Aldicarb Aldicarb Sulfone Aldicarb Sulfoxide Aldrin Butachlor Carbaryl Dicamba Dieldrin 3-Hydroxcarbofuran Methomyl Metolachlor Metribuzin Propachlor

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Yes Yes Yes

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No No No

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0 .2 40. 200

. 1. 500. 0 .5 4. 50. 3.
(No MCL) (No MCL) (No MCL) (No MCL) (No MCL) (No MCL) (No MCL) (No MCL) (No MCL) (No MCL) (No MCL) (No MCL) (No MCL)

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

Unregulated SOCs

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

Preservative Used: Iced Na2S2O3 HCl H2SO4 Other:

Important Notes:
- 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 Shadeland Avenue Indianapolis, IN 46204-2251

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