ADEQ Form DWAR15 A & B "Drinking Water Analysis Reporting Form - Surface Water/Groundwater Under the Influence of Surface Water Treatment" - Arizona

What Is ADEQ Form DWAR15 A & B?

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;
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  • Fill out the form in our online filing application.

Download a fillable version of ADEQ Form DWAR15 A & B 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 DWAR15 A & B "Drinking Water Analysis Reporting Form - Surface Water/Groundwater Under the Influence of Surface Water Treatment" - Arizona

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DRINKING WATER ANALYSIS REPORTING FORM
SURFACE WATER/GROUNDWATER UNDER THE
INFLUENCE OF SURFACE WATER TREATMENT
*** Monthly Report ***
PUBLIC WATER SYSTEM INFORMATION
***
***
>>>> TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
[________________]
________________________________________________
PWS ID Number
PWS Name
[________________]
________________________________________________
Report Date
Owner/Contact Person
___________________________________ (_____)__________________________________
Owner/Contact Email Address
Owner/Contact Phone Number
MONTH [_____________]
SAMPLE LOCATION
MONITORING PERIOD
YEAR [_____________]
Treatment Plant Surface Water ID [TPSW_______]
TPSW Name [_____________________________]
*** COMBINED FILTER EFFLUENT TURBIDITY ***
>>>> TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
YES
NO
Was the treatment plant in operation for the month being reported?
If the treatment plant was not in operation for the entire month, record the number of days the
[___________]
treatment plant was in operation during the month.
[___________]
A. Total number of combined filtered water turbidity measurements taken
MAXIMUM TURBIDITY MEASUREMENT
[___________]
B. Number of turbidity samples exceeding the specified limits for the filtration technology used
Conventional or Direct Filtration Limit – 1 NTU
Slow Sand or Diatomaceous Earth (DE) Filtration Limit – 5 NTU
Alternative (cartridges, membranes, bags) Filtration Limit – 5 NTU
Record the date and value of turbidity measurements that exceed the specified limits for the filtration technology used
Date/Time of Occurrence
Turbidity Value (NTU)
Date/Time Reported to ADEQ
If none occurred, enter “NONE”
[___________]
C. Highest single turbidity reading for the month
95% TURBIDITY MEASUREMENT
D. Total number of filtered water turbidity measurements that are > the specified limits for the
[___________]
filtration technology used:
Conventional or Direct Filtration Limit – 0.3 NTU
Slow Sand or Diatomaceous Earth (DE) Filtration Limit – 1 NTU
Alternative (cartridges, membranes, bags) Filtration Limit – 1 NTU
E. The percentage of turbidity measurements that are > the specified limits:
/
[___________] %
X 100 =
D
A
I hereby certify that the information provided in this report is accurate and correct to the best of my k nowledge.
Authorized Signature [__________________________________________________________]
Page 1 of 4
DRINKING WATER ANALYSIS REPORTING FORM
SURFACE WATER/GROUNDWATER UNDER THE
INFLUENCE OF SURFACE WATER TREATMENT
*** Monthly Report ***
PUBLIC WATER SYSTEM INFORMATION
***
***
>>>> TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
[________________]
________________________________________________
PWS ID Number
PWS Name
[________________]
________________________________________________
Report Date
Owner/Contact Person
___________________________________ (_____)__________________________________
Owner/Contact Email Address
Owner/Contact Phone Number
MONTH [_____________]
SAMPLE LOCATION
MONITORING PERIOD
YEAR [_____________]
Treatment Plant Surface Water ID [TPSW_______]
TPSW Name [_____________________________]
*** COMBINED FILTER EFFLUENT TURBIDITY ***
>>>> TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
YES
NO
Was the treatment plant in operation for the month being reported?
If the treatment plant was not in operation for the entire month, record the number of days the
[___________]
treatment plant was in operation during the month.
[___________]
A. Total number of combined filtered water turbidity measurements taken
MAXIMUM TURBIDITY MEASUREMENT
[___________]
B. Number of turbidity samples exceeding the specified limits for the filtration technology used
Conventional or Direct Filtration Limit – 1 NTU
Slow Sand or Diatomaceous Earth (DE) Filtration Limit – 5 NTU
Alternative (cartridges, membranes, bags) Filtration Limit – 5 NTU
Record the date and value of turbidity measurements that exceed the specified limits for the filtration technology used
Date/Time of Occurrence
Turbidity Value (NTU)
Date/Time Reported to ADEQ
If none occurred, enter “NONE”
[___________]
C. Highest single turbidity reading for the month
95% TURBIDITY MEASUREMENT
D. Total number of filtered water turbidity measurements that are > the specified limits for the
[___________]
filtration technology used:
Conventional or Direct Filtration Limit – 0.3 NTU
Slow Sand or Diatomaceous Earth (DE) Filtration Limit – 1 NTU
Alternative (cartridges, membranes, bags) Filtration Limit – 1 NTU
E. The percentage of turbidity measurements that are > the specified limits:
/
[___________] %
X 100 =
D
A
I hereby certify that the information provided in this report is accurate and correct to the best of my k nowledge.
Authorized Signature [__________________________________________________________]
Page 1 of 4
DRINKING WATER ANALYSIS REPORTING FORM
SURFACE WATER/GROUNDWATER UNDER THE
INFLUENCE OF SURFACE WATER TREATMENT
*** Monthly Report ***
*** INDIVIDUAL FILTER TURBIDITY ***
>>>> TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
Note: If your system consists of two or fewer filters, you may conduct continuous monitoring of
[______]
combined filter effluent in lieu of conducting continuous monitoring of individual filter effluent. Systems
electing this option do not have to complete this page. Initial this line if you are electing this option
PUBLIC WATER SYSTEM INFORMATION
***
***
>>>> TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
[________________]
________________________________________________
PWS ID Number
PWS Name
[________________]
________________________________________________
Report Date
Owner/Contact Person
MONTH [_____________]
SAMPLE LOCATION
MONITORING PERIOD
YEAR [_____________]
Treatment Plant Surface Water ID [TPSW_______]
TPSW Name [_____________________________]
YES
NO
1. Was each individual filter monitored continuously?
YES
NO
2. Were measurements recorded every 15 minutes?
3. Was there a failure in the continuous filter monitoring or 15 minute recording equipment
that lasted 4 or more hours (i.e., 16 or more continuous filter turbidity readings/recordings
YES
NO
missed due to equipment failure) during the month? If yes, indicate the date(s), duration,
and individual filter grab sampling frequency on a separate sheet.
INDIVIDUAL FILTER EVENT
[___________]
Did any individual filter exceed
4. 1 NTU in two consecutive measurements taken 15 minutes apart? If yes, complete the
YES
NO
table below and indicate required follow -up status (Filter Profile).
5. 0.5 NTU in two consecutive measurements taken 15 minutes apart at the end of the first four
YES
NO
hours of continuous operation after the filter has been backwashed, or otherwise taken offline?
If yes, complete the table below and indicate required follow -up status (Filter Profile).
6. 1 NTU in two consecutive measurements taken 15 minutes apart at any time in each of
YES
NO
three consecutive months? If yes, complete the table below and indicate required follow -
up status (Individual Filter Self-Assessment).
7. Yes No 2 NTU in two consecutive measurements taken 15 minutes apart at any time in each
YES
NO
of two consecutive months? If yes, complete the table below and indicate required follow -
up status (Comprehensive Performance Evaluation CPE).
Individual
Date/Time of
Filter Number
Turbidity Value (NTU)
Follow-up Action Taken (Y/N)*
Filter Event
Occurrence
If filter profile was not completed for 4 or 5, attach explanation.
Attach additional table, if necessary
*
Was an event reported for any individual filter listed in the table above during the previous
YES
NO
[_____________________________]
month? If yes, identify which plant and filter(s)
I hereby certify that the information provided in this report is accurate and correct to the best of my k nowledge.
Authorized Signature [__________________________________________________________]
Page 2 of 4
DRINKING WATER ANALYSIS REPORTING FORM
SURFACE WATER/GROUNDWATER UNDER THE
INFLUENCE OF SURFACE WATER TREATMENT
*** Monthly Report ***
PUBLIC WATER SYSTEM INFORMATION
***
***
>>>> TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
[________________]
________________________________________________
PWS ID Number
PWS Name
[________________]
________________________________________________
Report Date
Owner/Contact Person
MONTH [_____________]
SAMPLE LOCATION
MONITORING PERIOD
YEAR [_____________]
Treatment Plant Surface Water ID [TPSW_______]
TPSW Name [_____________________________]
*** MINIMUM RESIDUAL DISINFECTION CONCENTRATION (RDC) ***
>>>> Entry Point to the Distribution (EPDS) Sampling Only - TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
YES
NO
Was the treatment plant in operation for the month being reported?
A. Total number of measurements of minimum residual disinfection concentration samples
[___________]
taken
B. Record the number of occurrences of RDC less than 0.2 mg/l entering the distribution
[___________]
system during the month
C. Record the lowest measurement of RDC in mg/l entering the distribution system. Put a "NO" if the plant was
not operating for that day.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
D. Record any occurances of RDC less than 0.2 mg/L entering the distribution system
Date/Time Reported to
Hours until restored to
Date follow-up report to
Date/Time of Occurrence
ADEQ
0.2 mg/L or above
ADEQ
I hereby certify that the information provided in this report is accurate and correct to the best of my k nowledge.
Authorized Signature [__________________________________________________________]
Page 3 of 4
DRINKING WATER ANALYSIS REPORTING FORM
SURFACE WATER/GROUNDWATER UNDER THE
INFLUENCE OF SURFACE WATER TREATMENT
*** Monthly Report ***
PUBLIC WATER SYSTEM INFORMATION
***
***
>>>> TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
[________________]
________________________________________________
PWS ID Number
PWS Name
[________________]
________________________________________________
Report Date
Owner/Contact Person
MONTH [_____________]
MONITORING PERIOD
YEAR [_____________]
*** MINIMUM RESIDUAL DISINFECTION CONCENTRATION (RDC) ***
>>>> Distribution System Sampling Only - TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
MINIMUM RESIDUAL DISINFECTION CONCENTRATION
RDC must be measured at the same points and times as the microbiological samples are
collected. Calculate the "V" value for the month.
A. [_________]
Number of instances where the RDC was measured
Number of instances where the RDC was measured but not detected
B. [_________]
Calculate “V” value (the percentage of undetected residuals found)
/
[___________] %
X 100 =
B
A
I hereby certify that the information provided in this report is accurate and correct to the best of my k nowledge.
Authorized Signature [__________________________________________________________]
Subm it all four (4) pages to:
EMAIL:
WQD_Compliance_Data@azdeq.gov
-or- MAIL: ADEQ Water Quality Compliance Data Unit (MC 5415B-1),
DWAR 15 A & B:
For questions call: (602) 771-9200
1110 W. Washington St., Phoenix, AZ 85007.
Revised 12/2017
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