MDEQ FORM #3 – ORGANIC CHEMICAL USE BASE LIST
Public Water
System:_________________________________
PWSID #:___________________
Address:_______________________________________________________________________
City:__________________________________________County:___________________________
Contact Person:
________________________________Telephone:__________________________
Activity or Land Use:__________________________
Map Locator Number:___________________
Indicate which of the following organic chemicals are being used or have
been used in the past by this land use or activity.
Volatile Organic Chemicals (Regulated
chemicals only)
benzene
carbon tetrachloride
para-dichlorobenzene
ortho-dichlorobenzene
1,2-dichloroethylene
1,1-dichloroethylene
cis-1,2-dichloroethylene
trans-1,2-dichloroethylene
dichloromethane
1,2-dichloropropane
ethylbenzene
monochlorobenzene
styrene
tetrachloroethylene
toluene
1,2,4-trichlorobenzene
1,1,1-tricholroethane
1,1,2-trichloroethane
trichloroethylene
vinyl chloride
xylenes
Synthetic Organic Chemicals (Includes
unregulated (u) chemicals)
alachlor
aldrin (u)
atrazine
butachlor (u)
carbaryl (u)
carbofuran
chlordane
2,4-D
dalapon
dicamba (u)
dieldrin (u)
dinoseb
endrin
heptachlor
heptachlor epoxide
3-hydroxycarbofuran (u)
lindane
methomyl (u)
methoxychlor
metolachlor (u)
metribuzin (u)
oxamyl (vydate)
picloram
pentachlorophenol
simazine
propachlor (u)
2, 4, 5-TP (silvex)
toxaphene
benzo (a) pyrene
hexacholrocyclopentadiene (HEX)
di (2-ethylhexyl) phthalate
hexachlorobenzene
di (2-ethylhexyl) adipate
List
compiled by:
________________________________Telephone:_____________________
Signature:______________________________________
Date:_________________________
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