Form DWAR18A "Drinking Water Analysis Reporting Form - Chlorine 0999/Chloramine 1006" - Arizona

What Is Form DWAR18A?

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 DWAR18A by clicking the link below or browse more documents and templates provided by the Arizona Department of Environmental Quality.

ADVERTISEMENT
ADVERTISEMENT

Download Form DWAR18A "Drinking Water Analysis Reporting Form - Chlorine 0999/Chloramine 1006" - Arizona

Download PDF

Fill PDF online

Rate (4.6 / 5) 22 votes
DRINKING WATER ANALYSIS REPORTING FORM
CHLORINE 0999/CHLORAMINE 1006
*** PWS using Chlorine or Chloramine as disinfection must
sample within the Distribution System ***
PUBLIC WATER SYSTEM INFORMATION
***
***
>>>> TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
[______________]
[______________]
________________________________________________
Report Date
PWS ID Number
PWS Name
THIS REPORT IS FOR (
):
Qtr 1
Qtr 2
Qtr 3
Qtr 4
of Year [___________]
CHECK ONE
A. NUMBER OF RDL SAMPLES COLLECTED DURING EACH OF THE
PAST THREE MONTHS
* RDL must be measured at the same points and time as the RTCR samples are collected.
LAST
2 MONTHS
3 MONTHS
MONTH
AGO
AGO
B. MONTHLY AVERAGE OF ALL SAMPLES COLLECTED IN EACH
MONTH FOR THE LAST 12 MONTHS
** During the first year of monitoring insert ‘N/A’ for months monitoring was not required.
LAST
2 MONTHS
3 MONTHS
MONTH
AGO
AGO
|
|
|
|
|
|
|
|
10
11
12
4 MONTHS
5 MONTHS
6 MONTHS
9 MONTHS
7 MONTHS
8 MONTHS
MONTHS
MONTHS
MONTHS
AGO
AGO
AGO
AGO
AGO
AGO
AGO
AGO
AGO
C. RUNNING ANNUAL AVERAGE OF MONTHLY AVERAGES FOR THE PREVIOUS 12 MONTHS
*** When calculating the annual average use monthly averages for only the last twelve months. If the system has not completed a
full year of monitoring, the annual average is calculated by adding the individual monthly averages, and dividing by the number of
months sampled.
D. DID THE ANNUAL AVERAGE IN C EXCEED THE MRDL OF 4.0 MG/L?
Yes
No
>>>> TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
I hereby certify that the information provided in this report is accurate and correct to the best of my knowledge.
Comment [________________________________________________________________________________________]
Contact Person [___________________]
Authorized Signature [________________________________]
Contact Email Address [__________________________]
Contact Phone Number [___________________________]
All units must be reported in
Submit completed form to:
milligrams per liter (mg/L)
EMAIL:
WQD_Compliance_Data@azdeq.gov
MAIL: ADEQ Water Quality Compliance Data Unit (MC 5415B-1) ,
For questions, go to: azdeq.gov/DWComplianceAssistance
1110 W. Washington St., Phoenix, AZ 85007.
DWAR 18A: Revised 12/2017
Page 1 of 1
DRINKING WATER ANALYSIS REPORTING FORM
CHLORINE 0999/CHLORAMINE 1006
*** PWS using Chlorine or Chloramine as disinfection must
sample within the Distribution System ***
PUBLIC WATER SYSTEM INFORMATION
***
***
>>>> TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
[______________]
[______________]
________________________________________________
Report Date
PWS ID Number
PWS Name
THIS REPORT IS FOR (
):
Qtr 1
Qtr 2
Qtr 3
Qtr 4
of Year [___________]
CHECK ONE
A. NUMBER OF RDL SAMPLES COLLECTED DURING EACH OF THE
PAST THREE MONTHS
* RDL must be measured at the same points and time as the RTCR samples are collected.
LAST
2 MONTHS
3 MONTHS
MONTH
AGO
AGO
B. MONTHLY AVERAGE OF ALL SAMPLES COLLECTED IN EACH
MONTH FOR THE LAST 12 MONTHS
** During the first year of monitoring insert ‘N/A’ for months monitoring was not required.
LAST
2 MONTHS
3 MONTHS
MONTH
AGO
AGO
|
|
|
|
|
|
|
|
10
11
12
4 MONTHS
5 MONTHS
6 MONTHS
9 MONTHS
7 MONTHS
8 MONTHS
MONTHS
MONTHS
MONTHS
AGO
AGO
AGO
AGO
AGO
AGO
AGO
AGO
AGO
C. RUNNING ANNUAL AVERAGE OF MONTHLY AVERAGES FOR THE PREVIOUS 12 MONTHS
*** When calculating the annual average use monthly averages for only the last twelve months. If the system has not completed a
full year of monitoring, the annual average is calculated by adding the individual monthly averages, and dividing by the number of
months sampled.
D. DID THE ANNUAL AVERAGE IN C EXCEED THE MRDL OF 4.0 MG/L?
Yes
No
>>>> TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
I hereby certify that the information provided in this report is accurate and correct to the best of my knowledge.
Comment [________________________________________________________________________________________]
Contact Person [___________________]
Authorized Signature [________________________________]
Contact Email Address [__________________________]
Contact Phone Number [___________________________]
All units must be reported in
Submit completed form to:
milligrams per liter (mg/L)
EMAIL:
WQD_Compliance_Data@azdeq.gov
MAIL: ADEQ Water Quality Compliance Data Unit (MC 5415B-1) ,
For questions, go to: azdeq.gov/DWComplianceAssistance
1110 W. Washington St., Phoenix, AZ 85007.
DWAR 18A: Revised 12/2017
Page 1 of 1