Water Supply (WS) Series Organic Data Return Form
Please fill in your information below:
Name: asi Client Code:
Company: US EPA ID #:
Address: DMRQA Permittee #:
City: State: Zip: Phone #:
email: Fax #:
Study #: asi Order #:
Now please fill in the </>, Reporting Value and Method Description for each parameter that you wish to report on. All values reported should be in the units provided in the units column.
Please enter the Inorganic Disinfection By-Products I sample lot number to the right
asi Lot #:
Inorganic Disinfection By-Products I
EPA Analyte #
</>
Reporting Value
Units
Method Description
Bromochloroacetic acid
0250
ug/L
Dibromoacetic acid
0157
ug/L
Dichloroacetic acid
0158
ug/L
Monobromoacetic acid
0160
ug/L
Monochloroacetic acid
0161
ug/L
Trichloroacetic acid
0162
ug/L
Please enter the Inorganic Disinfection By-Products II sample lot number to the right
asi Lot #:
Inorganic Disinfection By-Products II
EPA Analyte #
</>
Reporting Value
Units
Method Description
Chloral hydrate
0165
ug/L
Pesticides I
EPA Analyte #
</>
Reporting Value
Units
Method Description
Alachlor
0093
ug/L
Aldrin
0256
ug/L
Atrazine
0094
ug/L
Dieldrin
0258
ug/L
Endrin
0011
ug/L
Heptachlor
0095
ug/L
Heptachlor epoxide (beta)
0096
ug/L
Hexachlorobenzene
0172
ug/L
Hexachlorocyclopentadiene
0112
ug/L
Lindane (gamma-BHC)
0012
ug/L
Methoxychor
0013
ug/L
Propachlor
0259
ug/L
Simazine
0113
ug/L
Trifluralin
0244
ug/L
Please enter the Pesticides II sample lot number to the right
asi Lot #:
Pesticides II
EPA Analyte #
</>
Reporting Value
Units
Method Description
Chlordane (total)
0097
ug/L
Please enter the Pesticides III sample lot number to the right
asi Lot #:
Pesticides III
EPA Analyte #
</>
Reporting Value
Units
Method Description
Toxaphene
0014
ug/L
Please enter the Carbamates sample lot number to the right
asi Lot #:
Carbamates
EPA Analyte #
</>
Reporting Value
Units
Method Description
Aldicarb
0098
ug/L
Aldicarb Sulfone
0099
ug/L
Aldicarb Sulfoxide
0100
ug/L
Carbofuran
0101
ug/L
Methomyl
0245
ug/L
Oxamyl (Vydate)
0114
ug/L
Please enter the PCB's in water sample lot number to the right
asi Lot #:
PCB's in water
EPA Analyte #
</>
Reporting Value
Units
Method Description
PCBs as decachlorobiphenyl
0118
mg/Kg
Please enter the Herbicides I sample lot number to the right
asi Lot #:
Herbicides I
EPA Analyte #
</>
Reporting Value
Units
Method Description
Acifluorfen
0262
ug/L
2,4-D
0015
ug/L
Dalapon
0115
ug/L
Dicamba
0247
ug/L
Dinoseb
0116
ug/L
Pentachlorophenol
0102
ug/L
Picloram
0117
ug/L
2,4,5-TP [Silvex]
0016
ug/L
Please enter the Herbicides II sample lot number to the right
asi Lot #:
Herbicides II
EPA Analyte #
</>
Reporting Value
Units
Method Description
Diquat
0137
ug/L
Endothall
0138
ug/L
Glyphosate
0139
ug/L
Please enter the Regulated Volatiles sample lot number to the right
asi Lot #:
Regulated Volatiles
EPA Analyte #
</>
Reporting Value
Units
Method Description
Benzene
0039
ug/L
Carbon tetrachloride
0037
ug/L
Chlorobenzene
0049
ug/L
1,2-Dichlorobenzene
0054
ug/L
1,4-Dichlorobenzene
0041
ug/L
1,2-Dichloroethane
0035
ug/L
1,1-Dichloroethylene
0034
ug/L
cis-1,2-Dichloroethylene
0043
ug/L
trans-1,2-Dichloroethylene
0042
ug/L
Dichloromethane (Methylene chloride)
0055
ug/L
1,2-Dichloropropane
0044
ug/L
Ethylbenzene
0048
ug/L
Styrene
0053
ug/L
Tetrachloroethylene
0040
ug/L
Toluene
0047
ug/L
1,1,1-Trichloroethane
0036
ug/L
1,1,2-Trichloroethane
0061
ug/L
Trichloroethylene
0038
ug/L
1,2,4-Trichlorobenzene
0076
ug/L
Vinyl chloride
0032
ug/L
Xylenes, total
0090
ug/L
Please enter the Unregulated Volatiles sample lot number to the right
asi Lot #:
Unregulated Volatiles
EPA Analyte #
</>
Reporting Value
Units
Method Description
Bromobenzene
0067
ug/L
Bromochloromethane
0089
ug/L
Bromomethane
0069
ug/L
n-Butylbenzene
0079
ug/L
sec-Butlybenzene
0086
ug/L
tert-Butlybenzene
0085
ug/L
Chloroethane
0070
ug/L
Chloromethane
0068
ug/L
2-Chlorotoluene
0071
ug/L
4-Chlorotoluene
0072
ug/L
Dibromomethane
0057
ug/L
1,3-Dichlorobenzene
0066
ug/L
Dichlorodifluoromethane
0088
ug/L
1,1-Dichloroethane
0056
ug/L
1,3-Dichloropropane
0059
ug/L
2,2-Dichloropropane
0060
ug/L
1,1-Dichloropropene
0058
ug/L
cis-1,3-Dichloropropene
0152
ug/L
trans-1,3-Dichloropropene
0153
ug/L
Fluorotrichloromethane
0087
ug/L
Hexachlorobutadiene
0081
ug/L
Isopropylbenzene
0084
ug/L
4-Isopropyltoluene
0083
ug/L
n-Propylbenzene
0078
ug/L
1,1,1,2-Tetrachloroethane
0063
ug/L
1,1,2,2-Tetrachloroethane
0065
ug/L
1,2,3-Trichlorobenzene
0077
ug/L
1,2,3-Trichloropropane
0064
ug/L
1,2,4-Trimethylbenzene
0075
ug/L
1,3,5-Trimethylbenzene
0082
ug/L
Please enter the EDB/DBCP sample lot number to the right
asi Lot #:
EDB/DBCP
EPA Analyte #
</>
Reporting Value
Units
Method Description
1,2-Dibromo-3-chloropropane (DBCP)
0045
ug/L
Ethylene dibromide (EDB)
0046
ug/L
Please enter the Trihalomethanes sample lot number to the right
asi Lot #:
Trihalomethanes
EPA Analyte #
</>
Reporting Value
Units
Method Description
Bromodichloromethane
0019
ug/L
Bromoform
0018
ug/L
Chlorodibromomethane
0020
ug/L
Chloroform
0017
ug/L
Total Trihalomethanes
0021
ug/L
Please enter the Semivolatiles sample lot number to the right
asi Lot #:
Semivolatiles
EPA Analyte #
</>
Reporting Value
Units
Method Description
Acenaphthene
0189
ug/L
Acenaphthylene
0190
ug/L
Anthracene
0192
ug/L
Benzidine
0176
ug/L
Benzo(a)anthrecene
0177
ug/L
Benzo butyl phthalate
0254
ug/L
Benzo(b)fluoranthene
0178
ug/L
Benzo(k)fluoranthene
0179
ug/L
Benzo(g,h,i)perylene
0180
ug/L
Benzo(a)pyrene
0122
ug/L
Chrysene
0181
ug/L
Dibenzo(a,h)anthracene
0182
ug/L
Di-n-butylphthalate
0205
ug/L
Di(2-Ethylhexyl)adipate
0134
ug/L
Di(2-Ethylhexyl)phthalate
0136
ug/L
Diethyl phthalate
0208
ug/L
Dimethyl phthalate
0209
ug/L
Di-n-octylphthalate
0211
ug/L
Fluoranthene
0212
ug/L
Fluorene
0213
ug/L
Indeno(1,2,3-cd)pyrene
0218
ug/L
1-Methylnaphthalene  
ug/L
2-Methylnaphthalene  
ug/L
Naphthylene
0222
ug/L
Phenanthrene
0231
ug/L
Pyrene
0187
ug/L
Additional comments: