Form DWAR16B "Drinking Water Analysis Reporting Form - Bromate" - Arizona

What Is Form DWAR16B?

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 DWAR16B 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 DWAR16B "Drinking Water Analysis Reporting Form - Bromate" - Arizona

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DRINKING WATER ANALYSIS REPORTING FORM
BROMATE
*** PWS using Ozone as disinfection or oxidation must sample
at each Entry Point to the Distribution System (EPDS) using Ozone ***
PUBLIC WATER SYSTEM INFORMATION
***
***
>>>> TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
[_______________]
________________________________________________
PWS ID
PWS Name
[_______________]
[_____:________]
________________________________________________
Sample Date
Sample Time
Owner/Contact Person
(24HR CLOCK)
__________________________________
(_____)__________________________________
Owner/Contact Email Address
Owner/Contact Phone Number
SAMPLE TYPE
MONITORING PERIOD
Compliance Monitoring
MONTH/QUARTER [_________________]
YEAR [__________]
SAMPLE COLLECTION POINT
Entry Point to the Distribution System [EPDS_____ ]
Was Ozone used during this Monitoring Period?
SAMPLE SITE ID [____________________________]
- or -
Yes
No
*** BROMATE ANALYSIS ***
>>> TO BE COMPLETED BY LABORATORY PERSONNEL <<<
Analysis
Reporting
Contaminant
Cont.
Analysis
Analysis
Exceeds
MCL
Result
Method
Limit
Name
Code
Run Date
Run Time
MCL
0.010
Bromate
1011
How many Bromate Samples were collected over the last quarter? [_____________________________________]
How many Bromate Samples were collected over the last 12 month period? [______________________________]
What is the Bromate results running annual average (the last 12 months)? [_______________________________]
Does the running annual average exceed the MCL of 0.010 mg/L?
- or -
Yes
No
*** 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
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 16B: Revised 12/2017
DRINKING WATER ANALYSIS REPORTING FORM
BROMATE
*** PWS using Ozone as disinfection or oxidation must sample
at each Entry Point to the Distribution System (EPDS) using Ozone ***
PUBLIC WATER SYSTEM INFORMATION
***
***
>>>> TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
[_______________]
________________________________________________
PWS ID
PWS Name
[_______________]
[_____:________]
________________________________________________
Sample Date
Sample Time
Owner/Contact Person
(24HR CLOCK)
__________________________________
(_____)__________________________________
Owner/Contact Email Address
Owner/Contact Phone Number
SAMPLE TYPE
MONITORING PERIOD
Compliance Monitoring
MONTH/QUARTER [_________________]
YEAR [__________]
SAMPLE COLLECTION POINT
Entry Point to the Distribution System [EPDS_____ ]
Was Ozone used during this Monitoring Period?
SAMPLE SITE ID [____________________________]
- or -
Yes
No
*** BROMATE ANALYSIS ***
>>> TO BE COMPLETED BY LABORATORY PERSONNEL <<<
Analysis
Reporting
Contaminant
Cont.
Analysis
Analysis
Exceeds
MCL
Result
Method
Limit
Name
Code
Run Date
Run Time
MCL
0.010
Bromate
1011
How many Bromate Samples were collected over the last quarter? [_____________________________________]
How many Bromate Samples were collected over the last 12 month period? [______________________________]
What is the Bromate results running annual average (the last 12 months)? [_______________________________]
Does the running annual average exceed the MCL of 0.010 mg/L?
- or -
Yes
No
*** 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
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 16B: Revised 12/2017