Form Dwar-3a - Drinking Water Aroclor Analysis Reporting Form (Page 2 of 2) in pdf

Instructions for Using the Arizona Department of Environmental Quality

Aroclor Analysis Reporting Form

Revised 2010

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

system by ADEQ.

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.

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 PERSON NAME: The first and last name of the owner or owner's representative (contact person),

who should be contacted with sample results.

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

should be contacted with sample results. All phone 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. Mark only one sample type for form.

SAMPLE COLLECTION POINT/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 separate reporting forms, a different (unique) number is

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

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

the “Synthetic Organic Chemical Analysis Reporting Form”.

EXCEEDS REPORTING LIMIT: If the sample analysis results exceed any of the reporting limits, then further PCB testing

by Method 508A is required.

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 call

(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-3A Aroclor Analysis Report.

Form Dwar-3a - Drinking Water Aroclor Analysis Reporting Form Page 2