ADEQ Form DWAR3 "Drinking Water Analysis Reporting Form - Synthetic Organic Chemicals (Soc)" - Arizona

What Is ADEQ Form DWAR3?

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 April 1, 2018;
  • 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 DWAR3 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 DWAR3 "Drinking Water Analysis Reporting Form - Synthetic Organic Chemicals (Soc)" - Arizona

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DRINKING WATER ANALYSIS REPORTING FORM
SYNTHETIC ORGANIC CHEMICALS (SOC)
*** Entry Point to the Distribution System (EPDS) 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 or Composite Level Sample Exceedance
Compliance Monitoring
[___________________]
Original Violation Specimen Number
SAMPLE COLLECTION POINT
SAMPLE TYPE
Entry Point to the Distribution System [EPDS_____ ]
- or -
Confirmation
Re-Analysis
SAMPLE SITE ID [____________________________]
Confirmation Composite
Re-Sample
*** SYNTHETIC ORGANIC 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
2,4-D (2,4-
0.07
0.0001
2105
Dichlorophenoxyacetic acid)
0.05
0.0002
2,4,5-TP (Silvex)
2110
0.003
0.001
Toxaphene
2020
0.002
0.0002
Alachlor
2051
0.003
0.0001
2050
Atrazine
0.04
0.0009
Carbofuran
2046
0.001
0.00004
Pentachlorophenol
2326
0.002
0.0002
Chlordane
2959
0.0002
0.00002
Dibromochloropropane (DBCP) 2931
0.00005 0.00001
Ethylene dibromide (EDB)
2946
0.0004
0.00004
Heptachlor
2065
0.0002
0.00002
Heptachlor epoxide
2067
0.0002
0.00002
Lindane (BHC-Gamma)
2010
0.0002
0.00002
Benzo[a]pyrene
2306
0.2
0.001
2031
Dalapon
0.006
0.0006
Di(2-ethylhexyl)phthalate
2039
0.4
0.0006
Di(2-ethylhexyl)adipate
2035
0.007
0.0002
Dinoseb
2041
[_______________________]
Specimen Number
Comment [________________________________________]
DWAR 3: Revised 04/2018
Page 1 of 2
DRINKING WATER ANALYSIS REPORTING FORM
SYNTHETIC ORGANIC CHEMICALS (SOC)
*** Entry Point to the Distribution System (EPDS) 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 or Composite Level Sample Exceedance
Compliance Monitoring
[___________________]
Original Violation Specimen Number
SAMPLE COLLECTION POINT
SAMPLE TYPE
Entry Point to the Distribution System [EPDS_____ ]
- or -
Confirmation
Re-Analysis
SAMPLE SITE ID [____________________________]
Confirmation Composite
Re-Sample
*** SYNTHETIC ORGANIC 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
2,4-D (2,4-
0.07
0.0001
2105
Dichlorophenoxyacetic acid)
0.05
0.0002
2,4,5-TP (Silvex)
2110
0.003
0.001
Toxaphene
2020
0.002
0.0002
Alachlor
2051
0.003
0.0001
2050
Atrazine
0.04
0.0009
Carbofuran
2046
0.001
0.00004
Pentachlorophenol
2326
0.002
0.0002
Chlordane
2959
0.0002
0.00002
Dibromochloropropane (DBCP) 2931
0.00005 0.00001
Ethylene dibromide (EDB)
2946
0.0004
0.00004
Heptachlor
2065
0.0002
0.00002
Heptachlor epoxide
2067
0.0002
0.00002
Lindane (BHC-Gamma)
2010
0.0002
0.00002
Benzo[a]pyrene
2306
0.2
0.001
2031
Dalapon
0.006
0.0006
Di(2-ethylhexyl)phthalate
2039
0.4
0.0006
Di(2-ethylhexyl)adipate
2035
0.007
0.0002
Dinoseb
2041
[_______________________]
Specimen Number
Comment [________________________________________]
DWAR 3: Revised 04/2018
Page 1 of 2
DRINKING WATER ANALYSIS REPORTING FORM
SYNTHETIC ORGANIC CHEMICALS (SOC)
*** Entry Point to the Distribution System (EPDS) Only ***
[_______________]
________________________________________________
PWS ID Number
PWS Name
SAMPLE COLLECTION POINT
Entry Point to the Distribution System [EPDS_____ ]
SAMPLE SITE ID [____________________________]
*** SYNTHETIC ORGANIC 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
-8
-9
3x10
5x10
2,3,7,8-TCDD (Dioxin)
2063
0.02
0.0004
Diquat
2032
0.1
0.009
Endothall
2033
0.002
0.00001
Endrin
2005
0.7
0.006
2034
Glyphosate
0.001
0.0001
Hexachlorobenzene
2274
0.05
0.0001
Hexachlorocyclopentadiene 2042
0.2
0.002
Oxamyl
2036
0.5
0.0001
Picloram
2040
0.004
0.00007
Simazine
2037
0.04
0.0001
Methoxychlor
2015
Polychlorinated biphenyls
0.0005
0.0001
2383
(PCB)
*** 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 #1 [____________] #2 [____________] #3 [____________] #4 [____________] #5 [____________]
All units must be reported in
Subm it completed form to:
milligrams per liter (mg/L)
EMAIL:
WQD_Compliance_Data@azdeq.gov
-or- MAIL: ADEQ Water Quality Compliance Data Unit (MC 5415B-1),
For questions call: (602) 771-9200
1110 W. Washington St., Phoenix, AZ 85007.
DWAR 3: Revised 04/2018
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