DISINFECTANT RESIDUAL REPORT FORM (CHLORINE OR …
CHLORINE OR CHLORAMINES RESIDUAL
EXAMPLE REPORTING FORMAT
|QUARTERLY REPORTING PERIOD: |YEAR: |
|SYSTEM INFORMATION |
|PWS NAME: |
|PWS ID NUMBER: |
|CONTACT PERSON: |PHONE NUMBER: |
|E-MAIL ADDRESS (optional): |FAX NUMBER (optional): |
|DISINFECTANT RESIDUAL COMPLIANCE SUMMARY |
|Last 12 Months |1 |
|Does the RAA violate the Maximum Residual Disinfectant Level of 4.0 mg/L? (YES/NO) | |
*Also, for each disinfectant residual sample taken each month of the last quarter, provide the information requested in the table on page two of this format.
|DISINFECTANT RESIDUAL ANALYSIS RESULTS FOR REPORTING PERIOD |
|Sample Location |Date of Sample |Name of Person |Date of Analysis |Analytical Method|Analysis Information |Residual Disinfectant |
| |Collection |Collecting Sample|(mo/da/yr) | |Provide one of the following: |Analysis Result (mg/L) |
| |(mo/da/yr) | | | |(Unless the analysis is performed by a DEP/DOH employee) | |
| | | | | |Name & License number of licensed operator responsible for | |
| | | | | |analysis | |
| | | | | |or | |
| | | | | |Name & certification number of laboratory responsible for | |
| | | | | |analysis | |
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