Read all instructions carefully before completing the application. Applications must be typewritten.

Appendix A Tier 2 Application A This application is designed for use by laboratories seeking accreditation for samples analyzed for compliance with a National Pollution Discharge Elimination System (NPDES) permit issued under Minnesota Statutes, section 115.03, subdivision 5. Minnesota Statutes 144.98, subd. 8 and 9 allow exemption from compliance with parts of the national standards for accreditation for laboratories meeting certain requirements. To obtain this exemption and receive accreditation under this second tier, laboratories must follow the application process outlined in this document. All steps must be completed for the application to be approved. Grey boxed areas throughout the application are for MN ELAP use only! THE APPLICATION PROCESS Step 1: Read all instructions carefully before completing the application. Applications must be typewritten. Step 2: Fill in all required information on the application form provided. Attach the required documentation as specified on the application form. Step 3: Complete Section 4 and 5 by selecting the field of testing for the laboratory is seeking to be accredited. The laboratory may apply to be accredited for any routine analytical test and the necessary preparation procedure or comparison procedure. Please contact MN ELAP prior to requesting method variance, preparation technique variance, or Minnesota Rule variance requests. Please review all information entered into Scope of Accreditation. No changes will be accepted without written notification from the laboratory (Minnesota Rules 4740.2050, subpart 15). Step 4: Attach evaluated proficiency testing results for each requested field of testing. MN ELAP does not allow revised proficiency testing reports. The proficiency testing frequency must meet the requirements outlined in Minn. Statutes 144.98, Subd. 9. Appendix A, Page 1 of 20

Step 5: Review the terms and conditions of the application materials as written in Section 11 and sign the affidavit. The application will not be considered a valid application unless the application is signed with a notary witness. Step 6: Application fees will be calculated based on the number and types of preparation techniques and fields of testing requested. MN ELAP will generate and send an invoice to the primary contact upon receipt of the completed application. Fees will be assessed according to Minn. Statutes 144.98. Step 7: Please review the completed application for errors and omissions. Please use the application instructions steps to assess completeness. Step 8: Print all the application materials and supporting documents to be assembled in the application packet. Please do not staple, tape, three hole punch or otherwise bind the documents. Please place supplemental materials in the following order behind the main application form (Appendix A): Step 9: additional personnel, directions or maps to the laboratory (if applicable), additional requested fields of testing (if applicable) laboratory quality manual standard operating procedures for each requested field of testing graded proficiency test results for each requested filed of testing (please include all acceptable and not acceptable reports, if applicable) Send the completed application and supporting documentation to the Minnesota Department of Health s Environmental Laboratory Accreditation Program. The remittance types and address information is located in Section 9. Appendix A, Page 2 of 20

SECTION 1: LABORATORY IDENTIFICATION Please complete this section with care. The information contained within this section will be used for communication with the laboratory and will be used to generate the Scope of Accreditation. Attach additional sheets if necessary. Laboratory Information Laboratory Name (legal): USEPA Laboratory ID: Laboratory Description/Type: Web Address: State Lab ID: Issue Date: Expiration Date: Certificate Number: Physical Location of the Facility Primary Contact Person: Email: Street Address: City: State: Postal Code: County: Phone Number: Fax Number: Mailing Address Street Address: City: Postal Code: County: Billing Address Street Address: City: Postal Code: County: Hours of Operation Directions to the Laboratory Appendix A, Page 3 of 20

SECTION 2: IDENTIFICATION OF LABORATORY PERSONNEL The following information regarding personnel is required per Minnesota Statutes 144.98. Please see the qualifications for laboratory personnel Chapter 3 of the Quality Systems for Wastewater Analysis. Attach additional sheets, if necessary. Area of Responsibility Name Title Email Address Laboratory Owner Managing Agent Lab Manager/Director Operator of Responsible Charge (Minn. Statutes 115.73) Quality Manager (however titled) Primary Contact Appendix A, Page 4 of 20

SECTION 3: DOCUMENTATION REQUIRED The following documents must be attached to the application and must be available for inspection at the time of the onsite assessment. The laboratory must have a copy of the most recent revision of Standard Methods for the Examination of Water and Wastewater approved for use as stated in part 136 of Title 40 of the Code of Federal Regulations. The Standard Methods for the Examination of Water and Wastewater is prepared and published jointly by the American Public Health Association, the American Water Works Association, and the Water Environment Federation. The associations are represented by a Joint Editorial Board administered by the Standard Methods consensus organization (http://www.standardmethods.org/). Section 1020A of the Standard Methods for the Examination of Water and Wastewater and Minnesota Rules 4740.2085 list the required documents for a laboratory quality system. For additional information and manual content, please see Chapters 2 and 3 of this guide. Please indicate below the required documents attached to your laboratory s application. laboratory quality manual (including signatures and quality policy statement) organizational structure/organizational chart(s) job descriptions and staff responsibilities list of tests performed by the laboratory inventory of equipment and instrumentation used within the laboratory standard operating procedure for each requested analytical method graded proficiency test report for each requested field of testing Policies and procedures relating to all practices used for the analysis of environmental sampling, testing and assessment, including: analyst training and performance requirements procedures for sample handling and receiving sample control and documentation/chain of custody reference measurement standards and measurement traceability generation, approval, and control of policies and procedures Appendix A, Page 5 of 20

Policies and procedures, continued: procurement of supplies and reference material procedure for subcontractor s services (if applicable) internal quality control activities calibration and verification and maintenance of instrumentation/equipment data verification practices (QA samples, proficiency test schedule, and etc) feedback, complaints, and corrective action mechanism exception reporting data reductions, validation and reporting Performance assessments and reviews method detection limit and data precision and accuracy records archiving management reviews Appendix A, Page 6 of 20

SECTION 4: SELECT METHOD PREPARATIONS (IF APPLICABLE) Please select all preparation techniques, preparation comparison studies, and preparation technique variances used by the laboratory. Inorganic Inorganic Chemistry Digestion, autoclave Inorganic Chemistry Digestion, hotplate or HotBlock Inorganic Chemistry Distillation, macro Inorganic Chemistry Distillation, micro Inorganic Chemistry Distillation, MIDI Inorganic Chemistry Distillation, comparison study Inorganic Chemistry Extraction, separatory funnel liquid liquid (LLE) Inorganic Chemistry Extraction, solid phase (SPE) Others (please specify): Comparison Studies (please specify): Variances (please specify): Appendix A, Page 7 of 20

SECTION 5: REQUESTED SCOPE OF ACCREDITATION Please select all Clean Water Program fields of testing for which the laboratory seeks initial or renewal accreditation. Please complete this section with care. The information selected will be used to generate the Scope and Certificate of Accreditation. If necessary use an additional application template to request needed fields of testing, and please attach parameter and method lists from the facility s NPDES permit or contract requiring the analysis. Shaded areas are designated for MN ELAP use only. Clean Water Program Non Potable Water Category: Microbiology Applied Prep Required Parameter Method Technology PT Provider Name PT Study ID (Feb March) Other PT Studies (Minn. Statutes 144.98, subd. 9) Approved Coliform, fecal in presence of chlorine, number per 100 ml Coliform, fecal in presence of chlorine, number per 100 ml 9221 C E 1999 9221 C E 1999 MPN, 5 tube, 3 dilution MPN, 5 tube, 3 dilution Appendix A, Page 8 of 20

Clean Water Program Non Potable Water Category: Microbiology Applied Prep Required Parameter Method Technology PT Provider Name PT Study ID (Feb March) Other PT Studies (Minn. Statutes 144.98, subd. 9) Approved Coliform, fecal in presence of chlorine, number per 100 9222 D 1997 MF, single step Coliform, total number per 100 ml Coliform, total number per 100 ml Coliform, total in presence of chlorine, number per 100 ml 9221 B 2006 MPN, 5 tube, 3 dilution 9222 B 1997 MF, single step or two step 9221 B 1999 MPN, 5 tube, 3 dilution Coliform, total in presence of chlorine, number per 100 ml 9222 (B +B.5c) 1997 MF with enrichment E. coli, number per 100mL 9223 B 1997 MPN multiple tube/multiple well Appendix A, Page 9 of 20

Clean Water Program Non Potable Water Category: Inorganic Chemistry Applied Prep Required Parameter Method Technology PT Provider Name PT Study ID (Feb March) Other PT Studies (Minn. Statutes 144.98, subd. 9) Approved Ammonia (as N), mg/l 4500 NH3 B 1997 Manual distillation or gas diffusion (ph >11) Ammonia (as N), mg/l 4500 NH3 C 1997 Titration Ammonia (as N), mg/l 4500 NH3 D 1997 or E 1997 Electrode Ammonia (as N), mg/l 4500 E 1997 Electrode Ammonia (as N), mg/l 4500 NH3 G 1997 Automated phenate, Appendix A, Page 10 of 20

Clean Water Program Non Potable Water Category: Inorganic Chemistry Applied Prep Required Parameter Method Technology PT Provider Name PT Study ID (Feb March) Other PT Studies (Minn. Statutes 144.98, subd. 9) Approved Biological oxygen demand (BOD5), mg/l Carbonaceous biochemical oxygen demand (CBOD5), mg/l 5210 B 2001 (including Hach 10360 LDO) 5210 B 2001 (including Hach 10360 LDO) Dissolved Oxygen Depletion Dissolved Oxygen Depletion w/ inhibitor Chemical oxygen demand (COD), mg/l 5220 C 1997 Titrimetric Chemical oxygen demand (COD), mg/l 5220 D 1997 Spectrophotometric, manual or automatic Chlorine Total residual, mg/l 4500 Cl D 2000 Amperometric direct Appendix A, Page 11 of 20

Clean Water Program Non Potable Water Category: Inorganic Chemistry Applied Prep Required Parameter Method Technology PT Provider Name PT Study ID (Feb March) Other PT Studies (Minn. Statutes 144.98, subd. 9) Approved Chlorine Total residual, mg/l (low level) 4500 Cl E 2000 Amperometric direct. Chlorine Total residual, mg/l 4500 Cl B 2000 Chlorine Total residual, mg/l 4500 Cl C 2000 Chlorine Total residual, mg/l 4500 Cl F 2000 Chlorine Total residual, mg/l 4500 Cl G 2000. Iodometric direct Back titration ether end point DPD FAS Spectrophotometric, DPD Chromium VI dissolved, mg/l 3111 C 1999 AA chelationextraction Appendix A, Page 12 of 20

Clean Water Program Non Potable Water Category: Inorganic Chemistry Applied Prep Required Parameter Method Technology PT Provider Name PT Study ID (Feb March) Other PT Studies (Minn. Statutes 144.98, subd. 9) Approved Chromium VI dissolved, mg/l 3500 Cr C 2001 Ion Chromatography Chromium VI dissolved, mg/l 3500 Cr B 2001 Colorimetric (Diphenyl carbazide). Hydrogen ion (ph), ph units 4500 H+ 2000 Electrometric measurement Kjeldahl Nitrogen Total, (as N), mg/l 4500 Norg B 1997 or C 1997 and Manual digestion 20 and distillation or gas diffusion 4500 NH3 B 1997 Appendix A, Page 13 of 20

Clean Water Program Non Potable Water Category: Inorganic Chemistry Applied Prep Required Parameter Method Technology PT Provider Name PT Study ID (Feb March) Other PT Studies (Minn. Statutes 144.98, subd. 9) Approved Kjeldahl Nitrogen Total, (as N), mg/l 4500 NH3 C 1997 Titration Kjeldahl Nitrogen Total, (as N), mg/l 4500 NH3 D 1997 Electrode Kjeldahl Nitrogen Total, (as N), mg/l 4500 E 1997 Electrode Oil and grease Total recoverable, mg/l 5520 B 2001 Hexane extractable material (HEM): n Hexane extraction and gravimetry Orthophosphate (as P), mg/l. 4500 P F 1999 Automated Appendix A, Page 14 of 20

Clean Water Program Non Potable Water Category: Inorganic Chemistry Applied Prep Required Parameter Method Technology PT Provider Name PT Study ID (Feb March) Other PT Studies (Minn. Statutes 144.98, subd. 9) Approved Orthophosphate (as P), mg/l 4500 P E 1999 Manual single reagent Orthophosphate (as P), mg/l 4110 B 2000 Ion Chromatography Oxygen, dissolved, mg/l 4500 O F 2001 Winkler (Azide modification) Oxygen, dissolved, mg/l 4500 O G 2001 Electrode Phosphorus Total, mg/l 4500 P E (including Hach 8190) Manual Phosphorus Total, mg/l 4500 P F Automated ascorbic acid reduction Appendix A, Page 15 of 20

Clean Water Program Non Potable Water Category: Inorganic Chemistry Applied Prep Required Parameter Method Technology PT Provider Name PT Study ID (Feb March) Other PT Studies (Minn. Statutes 144.98, subd. 9) Approved Residue Total, mg/l 2540 B 1997 Residue filterable, mg/l 2540 C 1997 Gravimetric, 103 105 Gravimetric, 180 Residue non filterable (TSS), mg/l 2540 D 1997 Gravimetric, 103 105 C post washing of residue Residue settleable, mg/l 2540 F 1997 Sulfide (as S), mg/l 4500 S 2 F 2000 Sulfide (as S), mg/l 4500 S 2 D 2000 Sulfide (as S), mg/l 4500 S 2 G 2000 Volumetric, (Imhoff cone), or gravimetric Titrimetric (iodine) Colorimetric (methylene blue) Ion Selective Electrode Appendix A, Page 16 of 20

Please use the format below to request additional parameters and methods. The analytes and methods must be approved for use in part 136 of Title 40 of the Code of Federal Regulations as required by the facility s NPDES permit. Clean Water Program Non Potable Water Category: Other Applied Prep Required Parameter Method Technology PT Provider Name PT Study ID (Feb March) Other PT Studies (Minn. Statutes 144.98, subd. 9) Approved EAMPLE Appendix A, Page 17 of 20

SECTION 6: PREFERRED MONTH FOR ONSITE ASSESSMENT Please select below the preferred month (or months) for a scheduled onsite assessment of the laboratory. MNELAP will consider a laboratory s request when scheduling the onsite assessment but cannot guarantee availability of staff during the preferred months. March April May June July August September October SECTION 7: PROFICIENCY TESTING STUDIES For each proficiency testing study identified in Section 5, please attach the proficiency testing study vendor evaluated results with this application packet. Please attach all evaluated results (acceptable and not acceptable). MNELAP maintains a list of approved proficiency test providers on the program s webpage: http://www.health.state.mn.us/divs/phl/accreditation/ptproviders.html The studies must be conducted at the times and frequency described in Minn. Statutes 144.98, Subd. 9. Laboratories must analyze a PT study in February or March of each year. If the laboratory receives acceptable results on the initial attempt, no additional studies are required. If the laboratory fails the initial study, the laboratory must obtain a remedial PT study within 15 days of the notice of the failed PT result and must participate in a follow up study selected from available studies scheduled during July or August of the same year. Appendix A, Page 18 of 20

SECTION 8: TERMS AND CONDITIONS OF THE APPLICATION Please review the terms and condition of accreditation and provide authorized signature. Application Terms and Conditions Laboratory Name (legal): USEPA Laboratory ID: Affidavit: State of County of I hereby certify that I have read Minnesota Statutes 144.98 and Minnesota Rules, Chapter 4740 for accreditation procedures for Environmental Testing Laboratories and I am authorized thereunder to make an application for Certification by the Minnesota Department of Health (MDH). I further certify that all environmental testing information required for compliance will be provided and that I will allow representatives of the commissioner to perform on site inspections of the laboratory pursuant to the rules to assure compliance with accreditation standards. I understand and acknowledge that my laboratory is required to be continually in compliance with Minn. Statutes 144.98, and with the provisions in Minnesota Rules, Chapter 4740, regarding the certification requirements for environmental laboratories. I understand that the laboratory is subject to the enforcement and penalty provisions of the State of Minnesota. I certify that I have not submitted information through this application that is classified as "trade secret" or "not public" under the Minnesota Data Practices Act. I understand that accreditation program information is public unless designated by me as meeting conditions for trade secret classification. I certify that I am the designated representative of the applicant/owner and that there are no misrepresentations in my submitted information and any related documentation required for compliance with accreditation requirements. Signatures Authorized Lab Representative (print): Signature Title: Date (mm/dd/yyyy): Signature of Notary Public and Seal Stamp Subscribed and sworn to before me this day of. Appendix A, Page 19 of 20

SECTION 9: REVIEW AND SUBMIT THE COMPLETED APPLICATION Please review the completed application and use the application instruction steps to assess completeness. Please remit application and documents to the Minnesota Department of Health Laboratory Accreditation Program. Send completed applications by U.S. mail to: Minnesota Department of Health Environmental Laboratory Accreditation Program (ELAP) PO Box 64899 St. Paul, MN 55164 0899 If using a commercial delivery service or couriers please use the following address: Minnesota Department of Health Environmental Laboratory Accreditation Program (ELAP) 601 Robert Street North St. Paul, MN 55155 2531 If you need further assistance in completing your application, please contact MNELAP at: Telephone: 651 201 5200 Email: health.mnelap@state.mn.us Website: http://www.health.state.mn.us/accreditation Laboratory Number: MN ELAP USE ONLY Application Type (circle one): Initial Renewal Add Analyte Deposit Number: Date (mm/dd/yyyy): Check Number: Amount: Appendix A, Page 20 of 20