Form DWAR16E "Drinking Water Analysis Reporting Form - Chlorite - Monthly" - Arizona

What Is Form DWAR16E?

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 Form DWAR16E by clicking the link below or browse more documents and templates provided by the Arizona Department of Environmental Quality.

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Download Form DWAR16E "Drinking Water Analysis Reporting Form - Chlorite - Monthly" - Arizona

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DRINKING WATER ANALYSIS REPORTING FORM
CHLORITE - MONTHLY
*** PWS using Chlorine Dioxide as disinfection must sample a monthly Chlorite within the Distribution System ***
PUBLIC WATER SYSTEM INFORMATION
***
***
>>>> TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
PWS ID Number: AZ04 __________________
PWS Name: _________________________________________________________
________________________________
(_____)________________________
______________________________
Owner/Contact Person
Owner/Contact Phone Number
Owner/Contact Email Address
SAMPLE TYPE:
Monitoring Period:
Compliance Monitoring
Month [
]
Year [
]
*** CHLORITE ANALYSIS ***
>>> TO BE COMPLETED BY LABORATORY PERSONNEL <<<
Analysis
Analysis Run
Sample Location ID/Name
Result
Specimen #
Sample Date
Sample Time
Method
Date/Time
(i.e. DDBP1-1234 Main St.)
(mg/L)
Contaminant Name: Chlorite
Contaminant Code: 1009
Calculated Sample-Set Average:
MCL: 1.0 mg/L
I hereby certify that the information provided in this report is accurate and correct to the best of my knowledge:
Lab ID Number [AZ________]
Lab Name [________________________________]
Phone Number [______________________]
Lab Contact, Printed Name [______________________________]
Authorized Signature [____________________________________]
Comments [_________________________________________________________________________________________________________]
PWS Notification Date [_________________________]
PWS Person Notified [_____________________________________________]
Submit completed form to: EMAIL:
WQD_Compliance_Data@azdeq.gov
-or- MAIL: ADEQ Water Quality Compliance Data Unit MC5415B-1),
For questions, go to: azdeq.gov/DWComplianceAssistance
1110 W. Washington St., Phoenix, AZ 85007.
DWAR16E: Revised 12/2017
DRINKING WATER ANALYSIS REPORTING FORM
CHLORITE - MONTHLY
*** PWS using Chlorine Dioxide as disinfection must sample a monthly Chlorite within the Distribution System ***
PUBLIC WATER SYSTEM INFORMATION
***
***
>>>> TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
PWS ID Number: AZ04 __________________
PWS Name: _________________________________________________________
________________________________
(_____)________________________
______________________________
Owner/Contact Person
Owner/Contact Phone Number
Owner/Contact Email Address
SAMPLE TYPE:
Monitoring Period:
Compliance Monitoring
Month [
]
Year [
]
*** CHLORITE ANALYSIS ***
>>> TO BE COMPLETED BY LABORATORY PERSONNEL <<<
Analysis
Analysis Run
Sample Location ID/Name
Result
Specimen #
Sample Date
Sample Time
Method
Date/Time
(i.e. DDBP1-1234 Main St.)
(mg/L)
Contaminant Name: Chlorite
Contaminant Code: 1009
Calculated Sample-Set Average:
MCL: 1.0 mg/L
I hereby certify that the information provided in this report is accurate and correct to the best of my knowledge:
Lab ID Number [AZ________]
Lab Name [________________________________]
Phone Number [______________________]
Lab Contact, Printed Name [______________________________]
Authorized Signature [____________________________________]
Comments [_________________________________________________________________________________________________________]
PWS Notification Date [_________________________]
PWS Person Notified [_____________________________________________]
Submit completed form to: EMAIL:
WQD_Compliance_Data@azdeq.gov
-or- MAIL: ADEQ Water Quality Compliance Data Unit MC5415B-1),
For questions, go to: azdeq.gov/DWComplianceAssistance
1110 W. Washington St., Phoenix, AZ 85007.
DWAR16E: Revised 12/2017