State Form 4626 - Chemical Examination Of Water - Indiana State Department Of Health
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1INDIANA STATE DEPARTMENT OF HEALTH
Do not write in this space
Environmental Laboratory
th
Lab No. ________________
550 W. 16
Street, Suite B
Reset Form
INDIANAPOLIS, INDIANA 46202-2203
Date Rec. ______________
CHEMICAL EXAMINATION OF WATER
Date Rep._______________
FILL IN THIS SPACE.
Also, mail copy of report to:
Indiana State Department of Health is to mail report to:
________________________________________
_______________________________________________
Name
Name
________________________________________
_______________________________________________
Street
Street
_________________________ IN ____________
___________________________ IN ________________
________________
City or Town
ZIP
City or Town
ZIP
Name of Utility or Organization __________________________________________ Superintendent _______________________________________________
City or Town ____________________________________________________________________________________________________________________
Collected by __________________________________ Date Collected ___________________ Hour ______________________________________________
Where was sample collected? _________________________________________________ Bottle No. ____________________________________________
Name unusual conditions __________________________________________________________________________________________________________
PWS Identification Number ______________________________________________________________________
FIELD INFORMATION
LABORATORY EXAMINATION
Do not
Do not
Indicate all treatment this
Check
Check
Check
Check
mg/l
mg/l
sample has received
Check
No Treatment
MO Alkalinity as CaCO
Arsenic
3
Chlorination
Hardness as CaCO
Barium
3
Plain sedimentation
Turbidity
Cadmium
Aerated and settled
pH
Chromium (Total)
Potassium Permanganate
Copper
Coagulant Aide
Chlorides as Cl
Lead
Prechlorinated
Sulfates as SO
Mercury
4
Filtered
Phosphates as PO
Selenium
4
Postchlorinated
Silver
Zeolite softened
Fluorides as F
Copper
Lime-soda softened
Nitrate + Nitrite as N
Coagulated and settled
Nitrates as N
Iron
Phosphate treatment
Nitrite as N
Manganese
Sp. Cond. μmhos/cm
Fluoride treatment
Calcium
Organics
Magnesium
Endrin
Sodium
Lindane
Potassium
FIELD EXAMINATION
Methoxychlor
pH
2, 4-D
CO2 mg/l
2, 4, 5-TP
Radionuclides
pCi/l
Iron mg/l
Toxaphene
Gross Alpha
Gross Beta
REMARKS:
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
State Form 4626 (R5/9-07)
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