DRINKING WATER RADIOCHEMICAL ANALYSIS REPORT
Arizona Department of Environmental Quality
Drinking Water Radionuclides – Adjusted Gross Alpha, Radium 226 & 228, Uranium Analysis Report
***Samples To Be Taken At Entry Point Into 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 Collection Point
( EPDS # ___________________
COMPLIANCE SAMPLE TYPE:
Date Q1 Collected ____________
← Reduced Monitoring Date Q2 Collected ___________
← Quarterly Date Q3 Collected ___________
← Composite of four quarterly samples Date Q4 Collected ___________
***RADIONUCLIDE ANALYSIS***
(((To be filled out by laboratory personnel(((
***Combined Uranium must be reported in micrograms per liter***
Analysis MCL Reporting Contaminant Cont. Analysis Result Exceeds
Method Limit Name Code Run Date MCL
______ 15 pCi/L Adjusted Gross Alpha 4000 ________ ________ _______
______ 3 pCi/L Gross Alpha 4002 ________ ________
______ Radon 4004 ________ ________
______ 30 µg/L 1 µg/L Combined Uranium 4006 ________ ________ µg/L _______
______ Uranium 234 4007 ________ ________
______ Uranium 235 4008 ________ ________
______ Uranium 238 4009 ________ ________ _______
______ 5 pCi/L 1 pCi/L Combined Radium (226,228) 4010 ________ ________
______ 1 pCi/L Raduim 226 4020 ________ ________
______ 1 pCi/L Raduim 228 4030 ________ ________
***LABORATORY INFORMATION***
(((To be filled out by laboratory personnel(((
Specimen Number: _______________________________________
Lab ID Number: _________________________________________
Lab Name: _____________________________________________
Printed Name and Phone Number of Lab Contact:___________________________________________________________________
Comments: _________________________________________________________________________________________________
Authorized Signature: ________________________________________________________________________________________
Date Public Water System Notified: _________________________
DWAR 6: 11/2007
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