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BUYER: SELLER:
Name ________________________________________ Name __________________________________________________
Address _______________________________________ Address ________________________________________________
City ___________________________________________ City ____________________________________________________
State/Zip ______________________________________ State/Zip _______________________________________________
Signature/Date ________________________________ Signature/Date __
________________________________
For purchases made in Iowa:
This form must be signed and dated buy the buyer and seller prior to consummation of this sale.
This form should be retained on file by the seller for a minimum of two years.
VOLATILE ORGANIC CHEMICALS/VOC's (continued)
CARBON FILTERS TESTED: 1m Extruded carbon, Lead/Cyst
Substance Influent challenge Max.permissible Drinking water
concentration mg/L product water regulatory level
1
concentration mg/L (MCL/MAC) mg/L
1,1,2,2-tetrachloroethane 0.081 0.001 ---
Tetrachloroethylene 0.081 0.001 0.005
Toluene 0.078 0.001 1.000
2,4,5-TP (silvex) 0.270 0.0016 0.050
Tribromoacetic acid 0.042 0.001 ---
1,2,4-Trichlorobenzene 0.160 0.0005 0.070
1,1,1-Trichloroethane 0.084 0.0046 0.200
1,1,2-Trichloroethane 0.150 0.0005 0.005
Trichloroethelyne 0.180 0.001 0.005
Trihalomethanes (includes):
Chloroform (surrogate chemical) 0.300 0.015 0.080
Bromoform 0.300 0.015 0.080
Bromodichloromethane 0.300 0.015 0.080
Chlorodibromomethane 0.300 0.015 0.080
Xylenes (total) 0.070 0.001 10
PERFORMANCE DATA SHEETS
Water Filtration System, model WHAF-0435AC
Replacement Filter C (model WHAB-6011)
Notes:
1. These harmonized values were agreed upon by representatives of USEPA and Health Canada for the
purpose of evaluating products to the requirements of ANSI/NSF Standard 53.
2. Influent challenge levels are average influent concentrations determined in surrogate qualification testing.
3. Maximum permissible product water concentration was not observed but was set at the detection limit
of the analysis.
4. Maximum permissible product water concentration is set at a value determined in surrogate
qualification testing.
5. Maximum permissible product water level calculated at chloroform 95% breakthrough point as
determined in surrogate qualification testing.
6. The surrogate test results for heptachlor epoxide demonstrated a 98% reduction. These data were
used to calculate an upper occurrence concentration, which would produce a maximum product water
level at the MCL.
TESTED AND CERTIFIED TO ANSI/NSF® 42 & 53 FOR SPECIFIC CONTAMINANT CLAIMS AS VERIFIED AND SUBSTANTIATED BY TEST DATA