Form Dwar-10 - Drinking Water Composite Inorganic Chemical Analysis Reporting Form

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Arizona Department of Environmental Quality
Drinking Water Composite Inorganic Chemical Analysis Reporting Form
*** Entry Point to the Distribution System (EPDS) Only ***
PWS#
EPDS# Specimen Number
Sample Date
Time (24 hr) System Name
1
2
3
4
5
Owner/Contact Person
Phone Number
Fax Number
1
2
3
4
5
>3,300 Population
COMPLIANCE SAMPLE TYPE:
≤3,300 Population
COMPOSITE INORGANIC CHEMICAL ANALYSIS
>>>To be completed by laboratory<<<
Analysis
Analysis
Reporting
Contaminant
Cont.
Exceeds
Exceeds
MCL
Run
Result
Method
Limit
Name
Code
MCL
Reporting Limit
Date
0.010
0.002
Arsenic
1005
2
0.4
Barium
1010
0.005
0.001
Cadmium
1015
0.1
0.02
Chromium
1020
4
0.8
Fluoride
1025
0.002
0.0004
Mercury
1035
10
2
Nitrate (as N)
1040
1
0.2
Nitrite (as N)
1041
0.05
0.01
Selenium
1045
0.006
0.0012
Antimony
1074
0.004
0.0008
Beryllium
1075
0.2
0.04
Cyanide
1024
No MCL 0.05
Nickel*
1036
0.002
0.0004
Thallium
1085
No MCL 10
Sodium*
1052
Laboratory Information
>>>To be completed by laboratory personnel<<<
Lab ID Number: ______________________
Specimen Number_____________________
Name: _________________________________________________________________________________
Printed Name and Phone Number of Lab Contact: ______________________________________________
Authorized Signature: ____________________________________________________________________
Date Public Water System Notified: __________________________________________________________
Date(s) Public Water System(s) were notified: #1_____________________ #2________________________
#3________________________ #4________________________ #5________________________________
Comments: _____________________________________________________________________________
All units must be reported in milligrams per liter (mg/L)
*Contaminants without an MCL
DWAR-10: Revised 8/2009
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