Form DWAR32 "Drinking Water Analysis Reporting Form - Stage 2 Disinfection Byproducts (Tthm&haa5) - Individual Sample Report" - Arizona

What Is Form DWAR32?

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 DWAR32 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 DWAR32 "Drinking Water Analysis Reporting Form - Stage 2 Disinfection Byproducts (Tthm&haa5) - Individual Sample Report" - Arizona

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DRINKING WATER ANALYSIS REPORTING FORM
STAGE 2 DISINFECTION BYPRODUCTS (TTHM&HAA5)
Individual Sample Report
*** Distribution System Only ***
PUBLIC WATER SYSTEM INFORMATION
***
***
>>>> TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
[_______________]
________________________________________________
PWS ID Number
PWS Name
[_______________]
[_____:________]
________________________________________________
Sample Date
Sample Time
Owner/Contact Person
(24HR CLOCK)
__________________________________
(_____)__________________________________
Owner/Contact Email Address
Owner/Contact Phone Number
SAMPLE TYPE
Compliance Monitoring
SITE ID (TTHM / HAA5):
STAGE 2 Compliance Monitoring Site ID:
(Taken from Stage 2 Compliance Monitoring Plan
Ex. 1234 Main St. Tap)
(Taken from Stage 2 Compliance Monitoring Plan
-
Ex. 01-A)
*** DISINFECTION BYPRODUCTS ANALYSIS ***
>>> TO BE COMPLETED BY LABORATORY PERSONNEL <<<
Analysis
Reporting
Contaminant
Cont.
Analysis
Exceeds
MCL
Result
Method
Limit
Name
Code
Run Date
MCL
< 0.0010
Chloroform
2941
< 0.0010
Bromoform
2942
< 0.0010
Bromodichloromethane
2943
< 0.0010
Dibromochloromethane
2944
TTHM
0.080
2950
< 0.0020
Monochloracetic Acid
2450
< 0.0010
Dichloroacetic Acid
2451
< 0.0010
Trichloroacetic Acid
2452
< 0.0010
Monobromoacetic Acid
2453
< 0.0010
Dibromoacetic Acid
2454
HAA5
0.060
2456
*** 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
-or-
MAIL: ADEQ Water Quality Compliance Data Unit (MC 5415B-1),
For questions, go to: azdeq.gov/DWComplianceAssistance
DWAR 32: Revised 12/2017
1110 W. Washington St., Phoenix, AZ 85007.
DRINKING WATER ANALYSIS REPORTING FORM
STAGE 2 DISINFECTION BYPRODUCTS (TTHM&HAA5)
Individual Sample Report
*** Distribution System Only ***
PUBLIC WATER SYSTEM INFORMATION
***
***
>>>> TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
[_______________]
________________________________________________
PWS ID Number
PWS Name
[_______________]
[_____:________]
________________________________________________
Sample Date
Sample Time
Owner/Contact Person
(24HR CLOCK)
__________________________________
(_____)__________________________________
Owner/Contact Email Address
Owner/Contact Phone Number
SAMPLE TYPE
Compliance Monitoring
SITE ID (TTHM / HAA5):
STAGE 2 Compliance Monitoring Site ID:
(Taken from Stage 2 Compliance Monitoring Plan
Ex. 1234 Main St. Tap)
(Taken from Stage 2 Compliance Monitoring Plan
-
Ex. 01-A)
*** DISINFECTION BYPRODUCTS ANALYSIS ***
>>> TO BE COMPLETED BY LABORATORY PERSONNEL <<<
Analysis
Reporting
Contaminant
Cont.
Analysis
Exceeds
MCL
Result
Method
Limit
Name
Code
Run Date
MCL
< 0.0010
Chloroform
2941
< 0.0010
Bromoform
2942
< 0.0010
Bromodichloromethane
2943
< 0.0010
Dibromochloromethane
2944
TTHM
0.080
2950
< 0.0020
Monochloracetic Acid
2450
< 0.0010
Dichloroacetic Acid
2451
< 0.0010
Trichloroacetic Acid
2452
< 0.0010
Monobromoacetic Acid
2453
< 0.0010
Dibromoacetic Acid
2454
HAA5
0.060
2456
*** 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
-or-
MAIL: ADEQ Water Quality Compliance Data Unit (MC 5415B-1),
For questions, go to: azdeq.gov/DWComplianceAssistance
DWAR 32: Revised 12/2017
1110 W. Washington St., Phoenix, AZ 85007.