ADEQ Form DWAR04 "Drinking Water Analysis Reporting Form - Volatile Organic Chemicals (VOC)" - Arizona

What Is ADEQ Form DWAR04?

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 DWAR04 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 DWAR04 "Drinking Water Analysis Reporting Form - Volatile Organic Chemicals (VOC)" - Arizona

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DRINKING WATER ANALYSIS REPORTING FORM
VOLATILE ORGANIC CHEMICALS (VOC)
*** 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
Entry Point to the Distribution System [EPDS_____ ]
SAMPLE TYPE
SAMPLE SITE ID [____________________________]
- or -
Confirmation-MCL
Confirmation-Composite
*** VOLATILE 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
0.007
0.0005
1,1-Dichloroethylene
2977
0.2
0.0005
1,1,1-Trichlorothane
2981
0.005
0.0005
1,1,2-Trichloroethane
2985
0.005
0.0005
1,2-Dichloroethane
2980
0.005
0.0005
1,2-Dichloropropane
2983
0.005
0.0005
Benzene
2990
0.005
0.0005
Carbon Tetrachloride
2982
0.07
0.0005
cis-1,2 Dichloroethylene
2380
0.7
0.0005
Ethylbenzene
2992
0.1
0.0005
(mono)chlorobenzene
2989
0.6
0.0005
o-Dichlorobenzene
2968
0.075
0.0005
Para-Dichlorobenzene
2969
0.1
0.0005
Styrene
2996
0.005
0.0005
Tetrachloroethylene
2987
1
0.0005
Toluene
2991
[_______________________]
Specimen Number
Comment [________________________________________]
DWAR 04: Revised 12/2017
Page 1 of 2
DRINKING WATER ANALYSIS REPORTING FORM
VOLATILE ORGANIC CHEMICALS (VOC)
*** 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
Entry Point to the Distribution System [EPDS_____ ]
SAMPLE TYPE
SAMPLE SITE ID [____________________________]
- or -
Confirmation-MCL
Confirmation-Composite
*** VOLATILE 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
0.007
0.0005
1,1-Dichloroethylene
2977
0.2
0.0005
1,1,1-Trichlorothane
2981
0.005
0.0005
1,1,2-Trichloroethane
2985
0.005
0.0005
1,2-Dichloroethane
2980
0.005
0.0005
1,2-Dichloropropane
2983
0.005
0.0005
Benzene
2990
0.005
0.0005
Carbon Tetrachloride
2982
0.07
0.0005
cis-1,2 Dichloroethylene
2380
0.7
0.0005
Ethylbenzene
2992
0.1
0.0005
(mono)chlorobenzene
2989
0.6
0.0005
o-Dichlorobenzene
2968
0.075
0.0005
Para-Dichlorobenzene
2969
0.1
0.0005
Styrene
2996
0.005
0.0005
Tetrachloroethylene
2987
1
0.0005
Toluene
2991
[_______________________]
Specimen Number
Comment [________________________________________]
DWAR 04: Revised 12/2017
Page 1 of 2
DRINKING WATER ANALYSIS REPORTING FORM
VOLATILE ORGANIC CHEMICALS (VOC)
*** 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 [____________________________]
*** VOLATILE 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
0.1
0.0005
Trans-1,2 Dichloroethylene
2979
0.005
0.0005
Trichloroethylene
2984
0.002
0.0005
Vinyl Chloride
2976
10
0.0015
Xylenes, total
2955
0.07
0.0005
1,2,4-Trichlorobenzene
2378
0.005
0.0005
Dichloromethane
2964
*** 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 [_____________________________________]
All units must be reported in
Submit 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 04: Revised 12/2017
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