Form Dwar 2 - Drinking Water Asbestos Analysis Report

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Arizona Department of Environmental Quality
Drinking Water Asbestos Analysis Report
*** Samples To Be Taken At Distribution System or At EPDS Only ***
_______________
_____________________________________________________________________
System ID
System 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
For MCL or Composite Level Exceedance
Entry Point to Distribution System
____________Original Violation Specimen Number
(EPDS) # ___________________
Sample Type
Confirmation
___________________________
Confirmation-Composite
Sampling Site ID
*** ASBESTOS ANALYSIS ***
>>>To be completed by laboratory personnel<<<
Analysis
Analysis
Reporting
Contaminant
Cont.
Exceeds
Exceeds
MCL
Run
Result
Method
Limit
Name
Code
MCL
Reporting Limit
Date
7 MFL
0.2
Asbestos
1094
Laboratory Information
>>>To be filled out by laboratory personnel<<<
Lab ID Number_______________
Specimen Number:______________
Printed Name and Phone Number of Lab Contact:____________________________________________
Authorized Signature:___________________________________________________________________
Date Public Water System Notified:________________________________________________________
Comments: ___________________________________________________________________________
* All units must be reported in million fibers per liter (MFL)
DWAR 2: Revised 06/2009
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