Epichlorohydrin and Acrylamide Certification Form - Oregon
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Epichlorohydrin and Acrylamide Usage
Certification Form
|System ID: OR41 |Reporting Period/Year: |
|System Name: |County: |
I certify that polymer(s) was was not (Check box that applies)
used for treatment of drinking water during the reporting period.
If a polymer was used, it may have contained epichlorohydrin and acrylamide. In accordance with OAR 333-061-0030(7), I hereby certify that the product identification, listing, and maximum dosages applied during the reporting period were as follows:
|Polymer #1 Name: |Manufacturer: |
|Certification organization listing this product in compliance with NSF Standard 60 (check one): |
|NSF UL WQA Other None* |
|Allowable maximum use dosage in product listing : mg/L (ppm) |
|Actual maximum dosage applied during reporting period: mg/L (ppm) |
*OAR 333-061-0087(6) - Products added to public water systems must meet requirements of NSF Standard 60 or equiv.
|Polymer #2 Name: |Manufacturer: |
|Certification organization listing this product in compliance with NSF Standard 60 (check one): |
|NSF UL WQA Other None* |
|Allowable maximum use dosage in product listing : mg/L (ppm) |
|Actual maximum dosage applied during reporting period: mg/L (ppm) |
If needed, Include additional polymer information on back of form.
|Signature: ____________________________ |Date: |
|Certification Submitted by (Print): | |Telephone Number: |
| | |
PLEASE SUBMIT FORM IN JANUARY EACH CALENDAR YEAR TO:
Polymer Use Form
Oregon Health Authority – Drinking Water Services
P.O. Box 14450, Portland, OR 97293-0450
Fax: (971) 673-0694
Email: michelle.p.byrd@state.or.us
|Polymer #3 Name: |Manufacturer: |
|Certification organization listing this product in compliance with NSF Standard 60 (check one): |
|NSF UL WQA Other None* |
|Allowable maximum use dosage in product listing : mg/L (ppm) |
|Actual maximum dosage applied during reporting period: mg/L (ppm) |
*OAR 333-061-0087(6) - Products added to public water systems must meet requirements of NSF Standard 60 or equiv.
Comments and/or Questions:
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