1. Name of Laboratory or Facility (As it should appear on the Certificate):
2. Description of Laboratory: (check one)
State Health Laboratory
County Health Department / 
Other State Laboratory
Pollution Control Facility
Utility Laboratory
Federal Organization
University/Academic Dept.
Commercial Laboratory
Research Institution
Other (please describe):
State Health Laboratory:
3. Location (physical address) of Laboratory:
Street Address:
City: State: Zip:
4. Mailing Address: (if different from above)
Street Address
P.O. Box
City: State: Zip:
5. Description of geographical location: (simplified directions to the laboratory) [for initial certification only]
6. Name of Owner:
7. Address of Owner:
Street Address
City: State: Zip:
8. Name of Laboratory Director:
9. Area Code Telephone Extension ( ) Ext.
10. Name of Quality Assurance Officer:
11. Area Code Telephone Extension ( ) Ext.
12. Name of Contact Person:
13. Area Code Telephone Extension ( ) Ext.
14. Hours of operation:
15. E-mail Address:
16. Facsimile Number ( )
17. Certification Number (if already certified):
18. EPA ID:

If this application is an initial application, please provide the following documentation:

A copy of the laboratory quality manual

Demonstration of capability and MDL summary data for all requested analytes

Copies of analytical SOPs for all requested analytes

Proficiency testing results showing successful analysis for 2 PT studies

If this application is for additional methods for which certification is being requested, please provide the following documentation:

Demonstration of capability and MDL summary data for all requested analytes

Copies of analytical SOPs for all requested analytes

Reports of successful analysis of requested analytes in two PT studies

If this application is for renewal of certification, please provide the following documentation:

A copy of the laboratory quality manual if changes have been made since the last application

MDL summary data for all requested analytes

Copies of analytical SOPs for analytesrequested by certification officer

For all requested documentation, electronic format is preferred.

Personnel and Qualifications

Position/Title / Name / Education Level
Degree/major* / Specialized Training / Present Specialty / Experience
Laboratory Director
Manager
Supervisors
Instrument Operators
AA
TEM
ICP
ICP/MS
GC
GC/MS
HPLC
Other analysts

*If major is not chemistry, list hours of college level courses in chemistry.

Check the description which applies to the type of water tested in your laboratory:

Public Water Systems- either community or non-community

______Community (Domestic) – 15 service connections or 25 year-round residents. May report to EPA, must report to IDEM. EXAMPLES: towns, subdivisions, rural areas, apartment complexes, mobile home parks

______Non-community, non-transient – Used by the same 25 people over 6 months per year. Reports to IDEM. EXAMPLES: schools, churches, industry

______Non-community, transient – Used by 25 people over 6 months per year. Reports sent to EPA. EXAMPLES: truck stops, rest parks, camps, parks

If your laboratory is not located in Indiana, do you currently analyze or have pending contracts for analysis of samples for Indiana public water supplies?

Yes ______No ______

Procedures currently used for drinking water testing:

Include the reference used for the method [USEPA methods (revision), Standard Methods (edition), ASTM (revision), etc.]

Metals

Antimony______

Arsenic______

Barium______

Beryllium______

Cadmium______

Chromium______

Copper______

Lead______

Mercury______

Nickel______

Selenium______

Thallium______

Nonmetals

Nitrate______

Nitrite______

Fluoride______

Cyanide______

Pesticides

Alachlor______

Atrazine______

Chlordane______

Endrin______

Heptachlor______

Heptachlor epoxide______

Hexachlorobenzene______

Hexachlorocyclopentadiene______

Lindane______

Methoxychlor______

Simazine______

Toxaphene______

Carbamates

Carbofuran______

Oxamyl______

Herbicides

2,4-D______

2,4,5-TP______

Dalapon______

Dinoseb______

Pentachlorophenol______

Picloram______

Polychlorinated biphenyls

As decachlorobiphenyl______

Polyaromatic hydrocarbons

Benzo(a)pyrene______

Adipate/phthalate

Di(2-ethylhexyl)adipate______

Di(2-ethylhexyl)phthalate______

Miscellaneous SOCs

Diquat______

Endothall______

Glyphosate______

VOC

Benzene______

Carbon tetrachloride______

Chlorobenzene______

1,2-dichlorobenzene______

1,4-dichlorobenzene______

1,2-dichloroethane______

1,1-dichloroethylene______

cis-1,2-dichloroethylene______

trans-1,2-dichloroethylene______

1.2-dichloropropane______

Ethylbenzene______

Styrene______

Tetrachloroethylene______

Toluene______

1,1,1-trichloroethane______

Trichloroethylene______

Vinyl chloride______

Xylenes (total)______

Dichloromethane______

1,2,4-trichlorobenzene______

1,1,2-trichloroethane______

DBCP______

EDB______

Trihalomethanes

Bromodichloromethane______

Bromoform______

Chlorodibromomethane______

Chloroform______

Miscellaneous Analytes

Asbestos______

2,3,7,8-TCDD (dioxin)______

Disinfection Byproducts

Haloacetic acids 5______

Bromate______

Chlorite______