ADEQ Form DWAR2POU "Drinking Water Analysis Reporting Form - Inorganic Chemical (Iocs)" - Arizona

What Is ADEQ Form DWAR2POU?

This is a legal form that was released by the Arizona Department of Environmental Quality - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2017;
  • The latest edition provided by the Arizona Department of Environmental Quality;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of ADEQ Form DWAR2POU by clicking the link below or browse more documents and templates provided by the Arizona Department of Environmental Quality.

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Download ADEQ Form DWAR2POU "Drinking Water Analysis Reporting Form - Inorganic Chemical (Iocs)" - Arizona

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DRINKING WATER ANALYSIS REPORTING FORM
INORGANIC CHEMICAL (IOCs)
*** Point of Use (POU) Only ***
PUBLIC WATER SYSTEM INFORMATION
***
***
>>>> TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
[_______________]
________________________________________________
PWS ID Number
PWS Name
[_______________]
[_____:________]
________________________________________________
Sample Date
Sample Time
Owner/Contact Person
(24HR CLOCK)
__________________________________
(_____)__________________________________
Owner/Contact Email Address
Owner/Contact Phone Number
SAMPLE TYPE
For MCL Exceedance
Point of Use Compliance Monitoring
[___________________]
Original Violation Specimen Number
SAMPLE COLLECTION POINT
SAMPLE TYPE
POU Confirmation
Point of Use Number [POU ___________________]
SAMPLE SITE ID [____________________________]
*** INORGANIC CHEMICAL ANALYSIS ***
>>> TO BE COMPLETED BY LABORATORY PERSONNEL <<<
Analysis
Reporting
Contaminant
Cont.
Analysis
Exceeds
Exceeds
MCL
Result
Method
Limit
Name
Code
Run Date
MCL
Reporting Limit
0.010
0.005
Arsenic
1005
2
1
Barium
1010
0.005
0.0025
Cadmium
1015
0.1
0.05
Chromium
1020
4
0.5
1025
Fluoride
0.002
0.001
Mercury
1035
10
2.5
Nitrate (as N)
1040
1
0.25
Nitrite (as N)
1041
0.05
0.025
Selenium
1045
0.006
0.003
Antimony
1074
0.004
0.002
Beryllium
1075
0.2
0.1
Cyanide
1024
No MCL
Nickel *
1036
0.002
0.001
Thallium
1085
No MCL
Sodium *
1052
*** LABORATORY INFORMATION ***
>>> TO BE COMPLETED BY LABORATORY PERSONNEL <<<
[________________________]
Specimen Number
Comment [_________________________________________ __]
Lab ID Number [AZ________]
Lab Name [_______________________]
Phone Number [_________________]
Lab Contact, Printed Name [___________________]
Authorized Signature [________________________________]
PWS Notification Date [_______________]
PWS Person Notified [_____________________________________]
*
Contaminants w ith no MCL
Subm it completed form to:
EMAIL:
WQD_Compliance_Data@azdeq.gov
-or- MAIL: ADEQ Water Quality Compliance Data Unit (MC 5415B-1),
DWAR 2POU:
For questions call: (602) 771-9200
1110 W. Washington St., Phoenix, AZ 85007.
Revised 12/2017
DRINKING WATER ANALYSIS REPORTING FORM
INORGANIC CHEMICAL (IOCs)
*** Point of Use (POU) Only ***
PUBLIC WATER SYSTEM INFORMATION
***
***
>>>> TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
[_______________]
________________________________________________
PWS ID Number
PWS Name
[_______________]
[_____:________]
________________________________________________
Sample Date
Sample Time
Owner/Contact Person
(24HR CLOCK)
__________________________________
(_____)__________________________________
Owner/Contact Email Address
Owner/Contact Phone Number
SAMPLE TYPE
For MCL Exceedance
Point of Use Compliance Monitoring
[___________________]
Original Violation Specimen Number
SAMPLE COLLECTION POINT
SAMPLE TYPE
POU Confirmation
Point of Use Number [POU ___________________]
SAMPLE SITE ID [____________________________]
*** INORGANIC CHEMICAL ANALYSIS ***
>>> TO BE COMPLETED BY LABORATORY PERSONNEL <<<
Analysis
Reporting
Contaminant
Cont.
Analysis
Exceeds
Exceeds
MCL
Result
Method
Limit
Name
Code
Run Date
MCL
Reporting Limit
0.010
0.005
Arsenic
1005
2
1
Barium
1010
0.005
0.0025
Cadmium
1015
0.1
0.05
Chromium
1020
4
0.5
1025
Fluoride
0.002
0.001
Mercury
1035
10
2.5
Nitrate (as N)
1040
1
0.25
Nitrite (as N)
1041
0.05
0.025
Selenium
1045
0.006
0.003
Antimony
1074
0.004
0.002
Beryllium
1075
0.2
0.1
Cyanide
1024
No MCL
Nickel *
1036
0.002
0.001
Thallium
1085
No MCL
Sodium *
1052
*** LABORATORY INFORMATION ***
>>> TO BE COMPLETED BY LABORATORY PERSONNEL <<<
[________________________]
Specimen Number
Comment [_________________________________________ __]
Lab ID Number [AZ________]
Lab Name [_______________________]
Phone Number [_________________]
Lab Contact, Printed Name [___________________]
Authorized Signature [________________________________]
PWS Notification Date [_______________]
PWS Person Notified [_____________________________________]
*
Contaminants w ith no MCL
Subm it completed form to:
EMAIL:
WQD_Compliance_Data@azdeq.gov
-or- MAIL: ADEQ Water Quality Compliance Data Unit (MC 5415B-1),
DWAR 2POU:
For questions call: (602) 771-9200
1110 W. Washington St., Phoenix, AZ 85007.
Revised 12/2017