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TRIHALOMETHANES (TTHM) AND HALOACETIC ACIDS (HAA5) ANALYSES IN DRINKING WATER
State Form 53288 (6-07)

Reset Form DBP

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

PWSID

Please mail completed form to: Check this box only if NO DISINFECTION was used this quarter

I N
System Name

Main/Contracted Laboratory Name

Quarter Year 1st 2005 IDEM OWQ - Drinking Water - MC 66-34 100 N Senate Avenue 2nd 2006 Indianapolis, IN 46204-2251 3rd 2007 4th 2008 Certification ID:

TTHM Sampling Frequency 1 Sample/Plant/Year 1 Sample/Plant/Quarter 4 Samples/Plant/Quarter HAA5 Sampling Frequency 1 Sample/Plant/Year 1 Sample/Plant/Quarter 4 Samples/Plant/Quarter
Approved Result Method (ppb) 502.2 524.2 551.1 502.2 524.2 551.1 502.2 524.2 551.1 502.2 524.2 551.1 Approved Result Method (ppb) 552.1 552.2 6251B 552.1 552.2 6251B 552.1 552.2 6251B 552.1 552.2 6251B Unit Detection BDL (ppb) Level

TTHM
Lab Sample ID (must be provided) Collection Date (MM.DD.YY) Sampling Point (See Instructions)

-

Plant Lab Certification Number (Lab doing test)

. . . .
HAA5
Lab Sample ID (must be provided)

. . . .

MXT001 MGT002 MXT001 MGT002 MXT001 MGT002 MXT001 MGT002

MGT003 MGT004 MGT003 MGT004 MGT003 MGT004 MGT003 MGT004

-

-

. . . .

ug/L ug/L ug/L ug/L

. . . .

Collection Date (MM.DD.YY)

Sampling Point (See Instructions)

Plant Lab Certification Number (Lab doing test)

Unit Detection BDL (ppb) Level

. . . .
Completed By:
13501

. . . .

MXT001 MGT002 MXT001 MGT002 MXT001 MGT002 MXT001 MGT002

MGT003 MGT004 MGT003 MGT004 MGT003 MGT004 MGT003 MGT004

-

-

. . . .

ug/L ug/L ug/L ug/L

. . . .

Reviewed By: Signature:

Signature: Date:

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Phone No:

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-

Date:

MM / DD / YY

MM / DD / YY

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