Form DWAR12B "Drinking Water Analysis Reporting Form - Synthetic Organic Chemicals (Soc) Composite" - Arizona

What Is Form DWAR12B?

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 July 1, 2019;
  • 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 DWAR12B 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 DWAR12B "Drinking Water Analysis Reporting Form - Synthetic Organic Chemicals (Soc) Composite" - Arizona

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DRINKING WATER ANALYSIS REPORTING FORM
SYNTHETIC ORGANIC CHEMICALS (SOC) COMPOSITE
*** Entry Point to the Distribution System (EPDS) Only ***
PWS ID
PWS Name
EPDS ID
Specimen Number
Sample Date
Time (24 HR)
1
2
3
4
5
Owner/Contact Person
Phone Number
Email Address
1
2
3
4
5
Compliance Sample Type:
< 3,300 Population
> 3,300 Population
*** COMPOSITE SYNTHETIC ORGANIC CHEMICAL ANALYSIS ***
>>> TO BE COMPLETED BY LABORATORY PERSONNEL <<<
Analysis
Reporting
Contaminant
Cont.
Analysis
Exceeds
Exceeds
MCL
Result
Method
Limit
Name
Code
Run Date
MCL
Reporting Limit
2,4-D (2,4-
0.07
0.0001
2105
Dichlorophenoxyacetic acid)
0.05
0.0002
2,4,5-TP (Silvex)
2110
0.003
0.001
Toxaphene
2020
0.002
0.0002
Alachlor
2051
0.003
0.0001
2050
Atrazine
0.04
0.0009
Carbofuran
2046
0.001
0.00004
Pentachlorophenol
2326
0.002
0.0002
Chlordane
2959
0.0002
0.00002
Dibromochloropropane (DBCP) 2931
0.00005 0.00001
Ethylene dibromide (EDB)
2946
0.0004
0.00004
Heptachlor
2065
0.0002
0.00002
Heptachlor epoxide
2067
0.0002
0.00002
Lindane (BHC-Gamma)
2010
0.0002
0.00002
Benzo[a]pyrene
2306
0.2
0.001
2031
Dalapon
0.006
0.0006
Di(2-ethylhexyl)phthalate
2039
0.4
0.0006
Di(2-ethylhexyl)adipate
2035
0.007
0.0002
Dinoseb
2041
[_______________________]
Specimen Number
Comment [________________________________________]
DWAR 12B: Revised 07/2019
Page 1 of 2
DRINKING WATER ANALYSIS REPORTING FORM
SYNTHETIC ORGANIC CHEMICALS (SOC) COMPOSITE
*** Entry Point to the Distribution System (EPDS) Only ***
PWS ID
PWS Name
EPDS ID
Specimen Number
Sample Date
Time (24 HR)
1
2
3
4
5
Owner/Contact Person
Phone Number
Email Address
1
2
3
4
5
Compliance Sample Type:
< 3,300 Population
> 3,300 Population
*** COMPOSITE SYNTHETIC ORGANIC CHEMICAL ANALYSIS ***
>>> TO BE COMPLETED BY LABORATORY PERSONNEL <<<
Analysis
Reporting
Contaminant
Cont.
Analysis
Exceeds
Exceeds
MCL
Result
Method
Limit
Name
Code
Run Date
MCL
Reporting Limit
2,4-D (2,4-
0.07
0.0001
2105
Dichlorophenoxyacetic acid)
0.05
0.0002
2,4,5-TP (Silvex)
2110
0.003
0.001
Toxaphene
2020
0.002
0.0002
Alachlor
2051
0.003
0.0001
2050
Atrazine
0.04
0.0009
Carbofuran
2046
0.001
0.00004
Pentachlorophenol
2326
0.002
0.0002
Chlordane
2959
0.0002
0.00002
Dibromochloropropane (DBCP) 2931
0.00005 0.00001
Ethylene dibromide (EDB)
2946
0.0004
0.00004
Heptachlor
2065
0.0002
0.00002
Heptachlor epoxide
2067
0.0002
0.00002
Lindane (BHC-Gamma)
2010
0.0002
0.00002
Benzo[a]pyrene
2306
0.2
0.001
2031
Dalapon
0.006
0.0006
Di(2-ethylhexyl)phthalate
2039
0.4
0.0006
Di(2-ethylhexyl)adipate
2035
0.007
0.0002
Dinoseb
2041
[_______________________]
Specimen Number
Comment [________________________________________]
DWAR 12B: Revised 07/2019
Page 1 of 2
DRINKING WATER ANALYSIS REPORTING FORM
SYNTHETIC ORGANIC CHEMICALS (SOC) COMPOSITE
*** Entry Point to the Distribution System (EPDS) Only ***
PWS ID
PWS Name
EPDS ID
Specimen Number
Sample Date
Time (24 HR)
1
2
3
4
5
*** COMPOSITE SYNTHETIC ORGANIC CHEMICAL ANALYSIS ***
>>> TO BE COMPLETED BY LABORATORY PERSONNEL <<<
Analysis
Reporting
Contaminant
Cont.
Analysis
Exceeds
Exceeds
MCL
Result
Method
Limit
Name
Code
Run Date
MCL
Reporting Limit
-8
-9
3x10
5x10
2,3,7,8-TCDD (Dioxin)
2063
0.02
0.0004
Diquat
2032
0.1
0.009
Endothall
2033
0.002
0.00001
Endrin
2005
0.7
0.006
2034
Glyphosate
0.001
0.0001
Hexachlorobenzene
2274
0.05
0.0001
Hexachlorocyclopentadiene 2042
0.2
0.002
Oxamyl
2036
0.5
0.0001
Picloram
2040
0.004
0.00007
Simazine
2037
0.04
0.0001
Methoxychlor
2015
Polychlorinated biphenyls
0.0005
0.0001
2383
(PCB)
*** 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 #1 [____________] #2 [____________] #3 [____________] #4 [____________] #5 [____________]
All units must be reported in
Subm it completed form to:
milligrams per liter (mg/L)
E MAIL:
WQD_Compliance_Data@azdeq.gov
-or- MAIL: ADEQ Water Quality Compliance Data Unit (MC 5415B-1),
For questions visit:
azdeq.gov/DWComplianceAssistance
1110 W. Washington St., Phoenix, AZ 85007
DWAR 12B: Revised 07/2019
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