Page
Water Quality Monitoring
of
DHS Drinking Water Program
Sanitary Survey
Name of System:
Contaminant
PWS ID#:
N/A
Frequency
41
Next Tests Due
Coliform Bacteria……….……….……..….……….
Nitrate……….……….……….………………….….
Arsenic……….……….……….………….…………
Inorganic Chemicals (sw) ………………….……..
Inorganic Chemicals (gw) ………...……….……..
SOC’s……….……….……….…..…….….…….….
VOC’s (sw) ……….……….…….….……..….……
VOC’s (gw) ……….……….……….………...….…
Radiologicals……….……….….…….………........
Asbestos……….……….……….……….………...
TTHM’s and HAA5’s……….…..……….………...
Lead and Copper, # Sites:
TOC……….……….……….……….……….……..
Turbidity……….……….……….……….……….…
Source Water Coliform……….……….…………..
Other: (Specify)
Yes
No
 Is all required monitoring current?
Comments:
Yes
No
Has the system experienced chemical (last 5 years) or bacteriological (last 2 years) detections?
If yes, what contaminant and when?
 Have all MCL violations been addressed?
Does the system have any monitoring reductions granted? Explain:
 Does the system have a written coliform sampling plan?
Does the plan include: Yes No
Brief narrative
Distribution map?
Sample site locations?
Yes
No
Rotation schedule?
Repeat locations?
Where in the system are the monitoring sites for TTHM and HAA5: (
Not required)
Are TTHM and HAA5 samples taken at location of maximum residence time?
Comments:
DHS 8516 (02/08)