Form Dwar-10 - Drinking Water Composite Inorganic Chemical Analysis Reporting Form (Page 2 of 2) in pdf

Instructions for Using the Arizona Drinking Water

Composite Inorganic Chemical Analysis Reporting Form

Revised 2009

PWS ID: This is a unique 5 digit Public Water System Identification (PWSID) number assigned to each public water

system by ADEQ. All water system id numbers need to be listed.

SYSTEM NAME: This should be the legal name which the water system has registered with the Arizona Corporation

Commission (ACC). If the system is a municipality or other non ACC regulated entity, this should reflect the legal

structure, such as XYZ Water Improvement District. Always notify the Department in writing of any name or ownership

change. All water system names need to be listed.

SAMPLE DATE: The date the specimen was collected in mm/dd/yy format.

SAMPLE TIME: The time the specimen was collected in hh:mm format (24 hr clock time).

OWNER/CONTACT PHONE#: The daytime phone number of the owner, or owner’s representative (contact person), who

should be contacted with sample results. All numbers need to be listed.

OWNER/CONTACT PHONE#: The daytime phone number of the owner or owner’s representative, (contact person) who

should be contacted with sample results. All numbers need to be listed.

SAMPLE TYPE: State the compliance reason for specimen collection. Only the relevant sample types for each

contaminant group are provided on the ADEQ forms.

EPDS ID: The location within the water system where the sample was taken and its assigned identifying number. Entry

Point to the Distribution System (EPDS) location – use this location for inorganic and organic chemical samples. Each

sample is taken at the EPDS, which means the point at which water is discharged into the distribution system from the

well, storage tank, pressure tank, or treatment facility. It is after treatment but prior to the first service connection. The

three digit number is assigned by ADEQ. All EPDS numbers need to be listed.

SAMPLING SITE ID: This is for your convenience so that you may put in an address or other location. This does not

need to be completed.

SPECIMEN NUMBER: A unique 15 character (max) alphanumeric code that identifies a particular sample used to test

one contaminant or one category of contaminants. If reporting on different reporting forms, a different (unique) number is

required for each contaminant group and for each report. If the sample analysis results exceed the composite reporting

level, and you are required to take a confirmation sample, this number will be used as the “Original Violating Specimen

number” on the “Composite Inorganic Chemical Analysis Reporting Form”.

FOR MCL EXCEEDENCE ONLY/ORIGINAL VIOLATING SPECIMEN NUMBER: This is the unique 15 character

(maximum length) alphanumeric code that identified the original specific sample that initiated the repeat/confirmation

sampling requirement (See SPECIMEN# above). If a MCL value is exceeded, use the specimen id number associated

with that MCL value.

PLEASE MAIL COMPLETED FORM TO:

ARIZONA DEPARTMENT OF ENVIRONMENTAL QUALITY

WATER QUALITY COMPLIANCE DATA UNIT (MC 5415B-1)

1110 W. WASHINGTON ST.

PHOENIX, AZ 85007

Fax: (602) 771-4505

NOTE: These definitions are general in nature. For specific questions regarding your laboratory submittal, please contact

(602) 771-4513 or within AZ 1-800-234-5677, ext. 4513.

___________________________________________________________________________________

Copies of this form are available from the ADEQ website at

Go to

, scroll down to laboratory reporting forms and click on

DWAR-10 Composite Inorganic Chemical Analysis Report.

Form Dwar-10 - Drinking Water Composite Inorganic Chemical Analysis Reporting Form Page 2

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