Application Form Pag1 rev1 04012016 -...

Qualitycheck S.r.l.s. Application form Qualitycheck Proficiency Testing - 2016 (Mod. PG05-1, rev1 del 26/07/2015) Phone: 0039 0621127870 – Fax: 0039 0656562874 website: www.qualitychecksrl.com Email: sales@qualitychecksrl.com

Qualitycheck Proficiency Testing Schemes Independent external evaluation of the analytical competence

of testing laboratories

Application Form - 2016

Customize your participation, and only pay for what you need! The laboratory may choose:

the measurands to be evaluated; the matrix of interest; the period in which to participate.

Instruction for the compilation 1 - Please complete the relevant pages, including “General Information”, selecting (please tick ✓ ) for each matrix the measurands and the period in which you want to participate.

2 - Send by email (sales@qualitychecksrl.com) or by FAX (0039 0656562874), the Application Form compiled.

3 - In three days, you will receive our Quote with the price of participation, including the transportation cost.

Distribution Schedule 2016 - Qualitycheck Proficiency Testing Schemes

Qualitycheck S.r.l.s. Telefono: 0039 0621127870 – Fax: 0039 0656562874 website: www.qualitychecksrl.com Email: sales@qualitychecksrl.com

(Mod. PG01-3, rev1 del 09/01/2016)

Qualitcyheck Proficiency Testing Schemes↓ Jan /16 Feb/ 16 Mar/16 Apr/16 May/16 Jun/16 Jul/16 Aug/16 Sep/16 Oct/16 Nov/16 Dec/16 Microbiological parameters in drinking water Microbiological parameters in wastewater Physical-Chemical parameters in natural waters Physical-Chemical parameters in wastewater Metals in natural waters Metals in wastewater

d Marc

h 2016

e 2016

d Octo

Metals in contaminated soils Metals in sewage sludge PAHs in contaminated soils Pesticides in contaminated soils Leaching test according to standard EN 12457-2 Hydrocarbon Oil Index according to standard ISO 9377-2

d Apri

l 2016

mber 2

Registration deadline Proficiency testing scheme

Registration deadline

Despatch date

Reporting deadline

Final Report date

Round Registration deadline

Despatch date

Reporting deadline

Final Report date

March 2016 12 February 7 March 8 April 26 April September 2016 29 July 19 September 14 October 31 October April 2016 12 February 4 April 29 April 16 May October 2016 29 July 3 October 4 November 21 November June 2016 3 May 13 June 8 July 25 July

pag. 1 of 12 Qualitycheck S.r.l.s. Application form Qualitycheck Proficiency Testing - 2016 (Mod. PG05-1, rev1 del 26/07/2015) Phone: 0039 0621127870 – Fax: 0039 0656562874 website: www.qualitychecksrl.com Email: sales@qualitychecksrl.com

Qualitycheck Proficiency Testing Schemes Independent external evaluation of the analytical competence

of testing laboratories

Application Form - 2016

General information Contact Name (first name and last name):

Name of Organization:

Address for shipment of the proficiency testing items Street Address: Postal Code: City/ Province/Country: Phone / Fax: Email: PRIVACY In accordance with and in compliance with the privacy Italian law (Dlgs. 30 June 2003, n. 196) we authorize the use of personal data for any purpose related to this service. DATE: _______________________ SIGNATURE: _______________________________________

Qualitycheck Proficiency Testing Schemes Application Form - 2016

pag. 2 of 12 Qualitycheck S.r.l.s. Application form Qualitycheck Proficiency Testing - 2016 (Mod. PG05-1, rev1 del 26/07/2015) Phone: 0039 0621127870 – Fax: 0039 0656562874 website: www.qualitychecksrl.com e-mail: sales@qualitychecksrl.com

Note: Measurement methods for the determination of the Colony Forming Units (CFU/ml). WASTEWATER

Round requited (please tick ✓ ) March 2016 June 2016 October 2016 07 Mar 26 Apr 06 Jun 18 Jul 03 Oct 21 Nov

Total Coliforms ⃝ ⃝ ⃝ Fecal Coliforms ⃝ ⃝ ⃝ Escherichia coli ⃝ ⃝ ⃝

Enterococci ⃝ ⃝ ⃝ Salmonella spp (presence/absence) ⃝ ⃝ ⃝

Note: Measurement methods for the determination of the Colony Forming Units (CFU/ml).

= Despatch date = Final Report date

MICROBIOLOGICAL PARAMETERS IN WATERS

DRINKING WATER Round requited (please tick ✓ ) March 2016 June 2016 October 2016 07 Mar 26 Apr 06 Jun 18 Jul 03 Oct 21 Nov

Total aerobic count at 22°C ⃝ ⃝ ⃝ Total aerobic count at 37°C ⃝ ⃝ ⃝

Batteri Coliformi ⃝ ⃝ ⃝ Escherichia coli ⃝ ⃝ ⃝

Enterococci ⃝ ⃝ ⃝ Pseudomonas Aeruginosa ⃝ ⃝ ⃝

PHYSICAL-CHEMICAL AND CHEMICAL PARAMETERS IN NATURAL WATERS Round requited (please tick ✓ )

March 2016 June 2016 October 2016 07 Mar 26 Apr 06 Jun 18 Jul 03 Oct 21 Nov

Alkalinity ⃝ ⃝ ⃝ Ammonia ⃝ ⃝ ⃝ Bromide ⃝ ⃝ ⃝ Calcium ⃝ ⃝ ⃝ Chloride ⃝ ⃝ ⃝

Conductivity ⃝ ⃝ ⃝ Fluoride ⃝ ⃝ ⃝

Magnesium ⃝ ⃝ ⃝ Nitrate ⃝ ⃝ ⃝ Nitrite ⃝ ⃝ ⃝

Permanganate index - ⃝ ⃝ pH ⃝ ⃝ ⃝

Phosphate ⃝ ⃝ ⃝ Potassium ⃝ ⃝ ⃝

Sodium ⃝ ⃝ ⃝ Sulphate ⃝ ⃝ ⃝

Total Dissolved Solids (Dried at 180°C) ⃝ ⃝ ⃝

Total Hardness ⃝ ⃝ ⃝ Total Organic Carbon (TOC) - ⃝ ⃝

Turbidity - ⃝ ⃝

PHYSICAL-CHEMICAL AND CHEMICAL PARAMETERS IN WASTEWATER Round requited (please tick ✓ ) March 2016 June 2016 October 2016 07 Mar 26 Apr 06 Jun 18 Jul 03 Oct 21 Nov

Ammonia Nitrogen ⃝ ⃝ ⃝ BOD5 ⃝ ⃝ ⃝

Chloride ⃝ ⃝ ⃝ COD ⃝ ⃝ ⃝

Conductivity ⃝ ⃝ ⃝ Fluoride ⃝ ⃝ ⃝

Nitrate Nitrogen ⃝ ⃝ ⃝ Nitrite Nitrogen ⃝ ⃝ ⃝

pH ⃝ ⃝ ⃝ Sulphate ⃝ ⃝ ⃝

Total Organic Carbon (TOC) ⃝ ⃝ ⃝ Total Nitrogen - ⃝ ⃝

Total phosphorus ⃝ ⃝ ⃝ Total suspended solids (TSS) - ⃝ ⃝

METALS IN NATURAL WATERS Round requited (please tick ✓ ) March 2016 June 2016 October 2016 07 Mar 26 Apr 06 Jun 18 Jul 03 Oct 21 Nov

Aluminum (Al) ⃝ ⃝ ⃝ Antimony (Sb) ⃝ ⃝ ⃝

Arsenic (As) ⃝ ⃝ ⃝ Barium (Ba) ⃝ ⃝ ⃝

Beryllium (Be) ⃝ ⃝ ⃝ Boron (B) ⃝ ⃝ ⃝

Calcium (Ca) - ⃝ ⃝ Cadmium (Cd) ⃝ ⃝ ⃝ Chromium (Cr) ⃝ ⃝ ⃝

Cobalt (Co) ⃝ ⃝ ⃝ Copper (Cu) ⃝ ⃝ ⃝

Iron (Fe) ⃝ ⃝ ⃝ Magnesium (Mg) - ⃝ ⃝ Manganese (Mn) ⃝ ⃝ ⃝

Mercury (Hg) ⃝ ⃝ ⃝ Molybdenum (Mo) ⃝ ⃝ ⃝

Nickel (Ni) ⃝ ⃝ ⃝ Lead (Pb) ⃝ ⃝ ⃝

Potassium (K) - ⃝ ⃝ Selenium (Se) ⃝ ⃝ ⃝

Silver (Ag) ⃝ ⃝ ⃝ Sodium (Na) - ⃝ ⃝ Thallium (Tl) ⃝ ⃝ ⃝

Tin (Sn) ⃝ ⃝ ⃝ Vanadium (V) ⃝ ⃝ ⃝

Zinc (Zn) ⃝ ⃝ ⃝ = Despatch date = Final Report date

METALS IN WASTEWATER Round requited (please tick ✓ ) March 2016 June 2016 October 2016 07 Mar 26 Apr 06 Jun 18 Jul 03 Oct 21 Nov

Aluminum (Al) ⃝ ⃝ ⃝ Antimony (Sb) ⃝ ⃝ ⃝

Arsenic (As) ⃝ ⃝ ⃝ Barium (Ba) ⃝ ⃝ ⃝

Beryllium (Be) ⃝ ⃝ ⃝ Boron (B) ⃝ ⃝ ⃝

Cadmium (Cd) ⃝ ⃝ ⃝ Chromium (Cr) ⃝ ⃝ ⃝

Chromium VI (Cr VI) - ⃝ ⃝ Cobalt (Co) ⃝ ⃝ ⃝

Copper (Cu) ⃝ ⃝ ⃝ Iron (Fe) ⃝ ⃝ ⃝

Manganese (Mn) ⃝ ⃝ ⃝ Mercury (Hg) ⃝ ⃝ ⃝

Molybdenum (Mo) ⃝ ⃝ ⃝ Nickel (Ni) ⃝ ⃝ ⃝ Lead (Pb) ⃝ ⃝ ⃝

Selenium (Se) ⃝ ⃝ ⃝ Silver (Ag) ⃝ ⃝ ⃝

Tin (Sn) ⃝ ⃝ ⃝ Vanadium (V) ⃝ ⃝ ⃝

Zinc (Zn) ⃝ ⃝ ⃝

METALS IN CONTAMINATED SOILS Round requited (please tick ✓ ) April 2016 September 2016 04 Apr 16 May 19 Sep 31 Oct Antimony (Sb) ⃝ ⃝ Arsenic (As) ⃝ ⃝ Beryllium (Be) ⃝ ⃝ Cadmium (Cd) ⃝ ⃝ Cobalt (Co) ⃝ ⃝ Chromium (Cr) ⃝ ⃝ Iron (Fe) ⃝ ⃝ Manganese (Mn) ⃝ ⃝ Mercury (Hg) ⃝ ⃝ Nickel (Ni) ⃝ ⃝ Lead (Pb) ⃝ ⃝ Copper (Cu) ⃝ ⃝ Selenium (Se) ⃝ ⃝ Tin (Sn) ⃝ ⃝ Thallium (Tl) ⃝ ⃝ Vanadium (V) ⃝ ⃝ Zinc (Zn) ⃝ ⃝

METALS IN SEWAGE SLUDGE Round requited (please tick ✓ ) April 2016 September 2016 04 Apr 16 May 19 Sep 31 Oct Aluminum (Al) ⃝ ⃝ Arsenic (As) ⃝ ⃝ Cadmium (Cd) ⃝ ⃝ Chromium (Cr) ⃝ ⃝ Cobalt (Co) ⃝ ⃝ Copper (Cu) ⃝ ⃝ Iron (Fe) ⃝ ⃝ Lead (Pb) ⃝ ⃝ Manganese (Mn) ⃝ ⃝ Mercury (Hg) ⃝ ⃝ Molybdenum (Mo) ⃝ ⃝ Nickel (Ni) ⃝ ⃝ Selenium (Se) ⃝ ⃝ Vanadium (V) ⃝ ⃝ Zinc (Zn) ⃝ ⃝

POLYCYCLIC AROMATIC HYDROCARBONS (PAHS) IN CONTAMINATED SOILS Round requited (please tick ✓ ) April 2016 September 2016 04 Apr 16 May 19 Sep 31 Oct Antracene ⃝ ⃝ Benzo(a)anthracene ⃝ ⃝ Benzo(a)pyrene ⃝ ⃝ Benzo(b)fluoranthene ⃝ ⃝ Benzo(g,h,i)perylene ⃝ ⃝ Benzo(k)fluoranthene ⃝ ⃝ Chrysene ⃝ ⃝ Dibenzo(a,h)anthracene ⃝ ⃝ Fluoranthene ⃝ ⃝ Indeno(1,2,3-cd)pyrene ⃝ ⃝ Phenantrene ⃝ ⃝ Pyrene ⃝ ⃝

PESTICIDES IN CONTAMINATED SOILS Round requited (please tick ✓ ) April 2016 September 2016 04 Apr 16 May 19 Sep 31 Oct Alachlor ⃝ ⃝ Aldrin ⃝ ⃝ Atrazine ⃝ ⃝ Chlordane (cis) ⃝ ⃝ Chlordane (trans) ⃝ ⃝ Chlordane (cis + trans) ⃝ ⃝ 2,4’-DDD ⃝ ⃝ 4,4’-DDD ⃝ ⃝ 2,4’-DDE ⃝ ⃝ 4,4’-DDE ⃝ ⃝ 2,4’-DDT ⃝ ⃝ 4,4’-DDT ⃝ ⃝ Dieldrin ⃝ ⃝ Diuron ⃝ ⃝ Endosulfan ⃝ ⃝ Endrin ⃝ ⃝ Hexachlorobenzene ⃝ ⃝ alfa-HCH ⃝ ⃝ beta-HCH ⃝ ⃝ gamma-HCH (Lindane) ⃝ ⃝ Simazine ⃝ ⃝

LEACHING TEST ACCORDING TO STANDARD EN 12457-2 (WASTES) Round requited (please tick ✓ ) April 2016 September 2016 04 Apr 16 May 19 Sep 31 Oct Antimony (Sb) ⃝ ⃝ Arsenic (As) ⃝ ⃝ Barium (Ba) ⃝ ⃝ Cadmium (Cd) ⃝ ⃝ Chromium (Cr) ⃝ ⃝ Copper (Cu) ⃝ ⃝ Lead (Pb) ⃝ ⃝ Mercury (Hg) ⃝ ⃝ Molybdenum (Mo) ⃝ ⃝ Nickel (Ni) ⃝ ⃝ Selenium (Se) ⃝ ⃝ Zinc (Zn) ⃝ ⃝ Chloride ⃝ ⃝ Conductivity ⃝ ⃝ Dissolved Organic Carbon (DOC) ⃝ ⃝ pH ⃝ ⃝ Sulfate ⃝ ⃝ Total dissolved solids (TDS) ⃝ ⃝

HYDROCARBON OIL INDEX ACCORDING TO STANDARD ISO 9377-2 (NATURAL WATER) Round requited (please tick ✓ ) April 2016 September 2016 04 Apr 16 May 19 Sep 31 Oct

Hydrocarbon Oil Index ⃝ ⃝

Application Form Pag1 rev1 04012016 -...

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