Form Dwar-3a - Drinking Water Aroclor Analysis Reporting Form
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1
2Arizona Department of Environmental Quality
Drinking Water Aroclor Analysis Reporting Form
*** Entry Point to the Distribution System (EPDS) Only ***
PWS ID#: AZ04 _______________
PWS Name: _______________________________________
____________ _______:_______ (24 hr clock)
(_____) ___________________________________________
Sample Date
Sample Time
Owner/Contact Person
(_____)_______________________
(_____)____________________________________________
Owner/Contact Fax Number
Owner/Contact Phone Number
Sample Type:
Compliance Monitoring
Sample Collection Point:
EPDS # _________________
___________________________
Sampling Site ID
AROCLOR (PCB SCREENING TEST)
>>>To be completed by laboratory personnel<<<
Analysis
Contaminant
Cont.
Analysis
Exceeds
Reporting Limit
Result
Method
Name
Code
Run Date
Reporting Limit*
.00008
Aroclor 1016
2388
.02
Aroclor 1221
2390
.0005
Aroclor 1232
2392
.0003
Aroclor 1242
2394
.0001
Aroclor 1248
2396
.0001
Aroclor 1254
2398
.0002
Aroclor 1260
2400
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: ___________________________________________________________
Comments: ______________________________________________________________________________
*If any reporting limit is exceeded, then further testing for decachlorobiphenyl must be conducted.
All units must be reported in milligrams per liter (mg/L)
DWAR-3A: Revised 2/2010
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