BSDW - 20 Revised 02/02
New Jersey Department of Environmental Protection Water Supply Administration - Bureau of Safe Drinking Water 401 East State Street, P.O. Box 426 Trenton, New Jersey 08625-0426 Tel (609) 292-5550 Fax (609) 292-1654
Page 1 of 2
Disinfection Byproduct Precursors Compliance Report
System Name: Address: City:
Number of paired TOC samples taken in quarter
#DIV/0!
PC
State:
Zip:
Period (check one)
PWSID # Facility Name: Facility ID #:
1st (Jan-March) 3rd (July-Sept) 2nd (Apr - June) 4th (Oct - Dec)
Check here if not in compliance
Treated Sample Location: A
Analysis Date mm/dd/yy Source Water TOC mg/l mg/l
Source Sample Location:
Sample Results
Month
Sample Date mm/dd/yy
B
Treated Water TOC mg/l mg/l mg/l mg/l mg/l
C
Source Water Alkalinity mg/l mg/l mg/l mg/l mg/l
D
E
F
Applicable Alternative criteria
G
D/E
(1-(B/A)) Required x 100 = TOC % removal %
1
mg/l mg/l mg/l Monthly Averages #DIV/0! mg/l mg/l mg/l
Code Value
#DIV/0!
mg/l mg/l mg/l mg/l mg/l mg/l
#DIV/0!
mg/l mg/l mg/l mg/l mg/l mg/l
#DIV/0! #DIV/0!
#DIV/0!
2
mg/l mg/l mg/l Monthly Averages #DIV/0! mg/l mg/l mg/l
Code Value
#DIV/0!
mg/l mg/l mg/l mg/l mg/l mg/l
#DIV/0!
mg/l mg/l mg/l mg/l mg/l mg/l
#DIV/0! #DIV/0!
#DIV/0!
3
mg/l mg/l mg/l Monthly Averages #DIV/0! mg/l
Code Value
#DIV/0!
mg/l
#DIV/0!
mg/l
#DIV/0! #DIV/0!
#DIV/0!
H
Month Value Col G
Compliance Determination If the average of Column G results for last twelve months < 1.0 not in compliance
Previous Quarter Previous Quarter Last quarter This Quarter
Running Annual Average #DIV/0!
#DIV/0! #DIV/0! #DIV/0!
If more than five paired samples per month use continuation sheet See page 2 of form for additional notes and further information
.
Check here if a continuation sheet used
I certify that these samples were collected in accordance with procedures approved by the New Jersey Department of Environmental Protection Name:
Purveyor Laboratory Approved Party
I certify that these samples were analyzed in accordance with procedures approved by the New Jersey Department of Environmental Protection Name: If applicable:
Laboratory Approved Party
Laboratory Name : Form prepared by: Purveyor Print Name Laboratory
Laboratory ID # Approved Party Phone Date
Signature of Representative
This form is available from the DEP web site at http://www.state.nj.us/dep/watersupply
BSDW - 21 Revised 02/02
New Jersey Department of Environmental Protection Water Supply Administration - Bureau of Safe Drinking Water 401 East State Street, P.O. Box 426 Trenton, New Jersey 08625-0426 Tel (609) 292-5550 Fax (609) 292-1654
Page of
PC
Disinfection Byproduct Precursors Compliance Report Continuation Sheet
System Name: Address: City:
Period Month 1st (Jan-March)
State:
2nd (Apr - June) A
Sample Date Analysis Date mm/dd/yy Source Water TOC mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l
Zip:
3rd (July-Sept) B
Treated Water TOC mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l
PWSID # Facility Name: Facility ID #:
4th (Oct - Dec) C
Source Water Alkalinity mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l
D
E
mm/dd/yy
(1-(B/A)) Required x 100 = TOC % removal %
I certify that these samples were collected in accordance with procedures approved by the New Jersey Department of Environmental Protection Name:
Purveyor Laboratory Approved Party
I certify that these samples were analyzed in accordance with procedures approved by the New Jersey Department of Environmental Protection Name: If applicable:
Laboratory Approved Party
Laboratory Name : Form prepared by: Purveyor Print Name Laboratory
Laboratory ID # Approved Party Phone Date
Signature of Representative
This form is available from the DEP web site at http://www.state.nj.us/dep/watersupply