Mail To: MARYLAND DEPARTMENT of the ENVIRONMENT

Mail to: MARYLAND DEPARTMENT OF THE ENVIRONMENT

WATER SUPPLY PROGRAM

1800 Washington Blvd., STE. 450, Baltimore, Maryland 21230-1708

(410) 537-3729 (800) 633-6101 ext. 3729 http://www.mde.state.md.us

SYNTHETIC ORGANIC SELF-MONITORING REPORT

PWSID______SYSTEM NAME ______COUNTY______

PLANT ID______PLANT NAME______

SAMPLE SITE ADDRESS______

SAMPLE TYPE: RAW _____ FINISHED_____SAMPLE LOCATION(well, sample tap, sink,etc.)______

DATE COLLECTED ______TIME______

SAMPLER ID______SAMPLER NAME______PHONE______

LAB CERT#: ______LABORATORY ______PHONE ______

LAB SAMPLE ID______RECEIVED______REPORTED______

REMARKS:______

Contaminant EPA ID MCL Actual Level Sample EPA Analytic Analysis

(ppb) (ppb) Preservation Method Used Date

Alachlor...... 2051 2 ______Atrazine...... 2050 3 ______

Carbofuran...... 2046 40 ______

Chlordane...... 2959 2 ______

DBCP...... 2931 0.2 ______504______

2,4-D...... 2105 70 ______

EDB...... 2946 0.05 ______504______

Heptachlor...... 2065 0.4 ______

Heptachlor epoxide..... 2067 0.2 ______

Lindane...... 2010 0.2 ______

Methoxychlor...... 2015 40 ______

PCB...... 2383 0.5 ______

Pentachlorophenol...... 2326 1 ______

Toxaphene...... 2020 3 ______

2,4,5-TP...... 2110 50 ______

I do hereby affirm that this record contains no willful misrepresentations or falsifications and that this information given by me is true to the best of my knowledge and belief. I further certify that the methods and quality control measures used to produce these laboratory results were implemented in accordance with the requirements of this laboratory's certification under COMAR 26.08.05.

SIGNED ______DATE ______

SOC/MDE/WMA/COM.007 (02/04) TTY Users 1-800-735-2258

Page 2 (must also include page 1)

ORGANIC SELF-MONITORING REPORT (CONT)

PHASE V AND UNREGULATED ORGANIC

Contaminant EPA ID MCL Actual Level Sample EPA Analytic Analysis

(ppb) (ppb) Preservation Method Used Date

Aldicarb...... 2047 3 ______

Aldicarb sulfoxide...... 2043 4 ______

Aldicarb sulfone...... 2044 2 ______

Dalapon...... 2031 200 ______

Dinoseb...... 2041 7 ______

Diquat...... 2032 20 ______549 ______

Endothall...... 2033 100 ______548 ______

Endrin...... 2005 2 ______

Glyphosate...... 2034 700 ______547 ______

Oxamyl(Vydate)...... 2036 200 ______

Picloram...... 2040 500 ______

Simazine...... 2037 4 ______

Benzo(a)pyrene...... 2306 0.2 ______

Di(ethylhexyl)adipate... 2035 400 ______

Di(ethylhexyl)phthalate 2039 6 ______

Hexachlorobenzene..... 2274 1 ______

Hexachlorocyclopentadiene 2042 50 ______

2,3,7,8-TCDD (Dioxin) 2063 3x10-5 ______513 ______

Unregulated Contaminants

Aldrin...... 2356 ______

Butachlor...... 2076 ______

Carbaryl...... 2021 ______

Dicamba...... 2440 ______

Dieldrin...... 2070 ______

3-Hydroxycarbofuran.. 2066 ______

Methomyl...... 2022 ______

Metolachlor...... 2045 ______

Metribuzin...... 2595 ______

Propachlor...... 2077 ______

SIGNED ______DATE______