ADEQ Form DWAR1R "Drinking Water Analysis Reporting Form - Microbiological/Revised Total Coliform Rule" - Arizona

What Is ADEQ Form DWAR1R?

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 DWAR1R 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 DWAR1R "Drinking Water Analysis Reporting Form - Microbiological/Revised Total Coliform Rule" - Arizona

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DRINKING WATER ANALYSIS REPORTING FORM
MICROBIOLOGICAL/REVISED TOTAL COLIFORM RULE
*** Distribution System 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
Special Purpose Sample for state information only (NOT FOR COMPLIANCE)
REPEAT SAMPLES ONLY – Check One
LOCATION ID:
* Use only if Routine Sample was Positive
Routine Positive Specimen ID [____________________]
(Ex. RTCR001)
Original Location (Distribution System)
SAMPLING SITE / TAP LOCATION:
Upstream Location (Distribution System)
Downstream Location (Distribution System)
Dual Purpose Sample taken at the Well *
Well 55-__________________
Cl
_________ mg/L
2
(Ex. 1234 Main St. Tap)
* Must have Regulatory Agency approval
(Not for MRDL Reporting)
*** MICROBIOLOGICAL ANALYSIS ***
>>> TO BE COMPLETED BY LABORATORY PERSONNEL <<<
3100
3014
Analysis Start
Analysis Complete
Total Coliform
E. coli
Specimen ID
Method
Result
Method
Result
Date
Time
Date
Time
If reporting for Dual Purpose, you must use method that provides E. coli as a result, and specify if E. coli is detected.
In case of any E. coli detected, contact your Compliance Assistance Coordinator by end of the business day (5pm).
*** 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 [_____________________________________]
Any positive routine or increased routine RTCR sample triggers the GWR and requires ADEQ notification:
ADEQ Notification Date [_______________]
ADEQ Person Notified [____________________________________]
PLEASE DO NOT SUBMIT
Submit completed form to:
MULTIPLE TIMES
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 1R: Revised 12/2017
DRINKING WATER ANALYSIS REPORTING FORM
MICROBIOLOGICAL/REVISED TOTAL COLIFORM RULE
*** Distribution System 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
Special Purpose Sample for state information only (NOT FOR COMPLIANCE)
REPEAT SAMPLES ONLY – Check One
LOCATION ID:
* Use only if Routine Sample was Positive
Routine Positive Specimen ID [____________________]
(Ex. RTCR001)
Original Location (Distribution System)
SAMPLING SITE / TAP LOCATION:
Upstream Location (Distribution System)
Downstream Location (Distribution System)
Dual Purpose Sample taken at the Well *
Well 55-__________________
Cl
_________ mg/L
2
(Ex. 1234 Main St. Tap)
* Must have Regulatory Agency approval
(Not for MRDL Reporting)
*** MICROBIOLOGICAL ANALYSIS ***
>>> TO BE COMPLETED BY LABORATORY PERSONNEL <<<
3100
3014
Analysis Start
Analysis Complete
Total Coliform
E. coli
Specimen ID
Method
Result
Method
Result
Date
Time
Date
Time
If reporting for Dual Purpose, you must use method that provides E. coli as a result, and specify if E. coli is detected.
In case of any E. coli detected, contact your Compliance Assistance Coordinator by end of the business day (5pm).
*** 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 [_____________________________________]
Any positive routine or increased routine RTCR sample triggers the GWR and requires ADEQ notification:
ADEQ Notification Date [_______________]
ADEQ Person Notified [____________________________________]
PLEASE DO NOT SUBMIT
Submit completed form to:
MULTIPLE TIMES
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 1R: Revised 12/2017