LEAD AND COPPER WATER QUALITY PARAMETER REPORT FORM 20679
Texas Commission on Environmental Quality – Public Drinking Water Section
SECTION I. Public Water System InformationPWSID#: TX / PWS NAME: / PHONE #:
PWS TYPE: COMM NTNC / POPULATION: >100,000 50,001 TO 100,000 < 50,000
PWS CONTACT NAME: TITLE DATE
PWS AUTHORIZED SIGNATURE:
SECTION II. WQP TYPE
INITIAL ANNUAL TRIENNIAL / TAP LEAD OR COPPER EXCEEDANCE: YES NO
DS SYSTEM ENTRY POINTS / # OF DS SAMPLES REQUIRED: # OF DS SAMPLES SUBMITTED:
# OF EP SAMPLES REQUIRED: # OF EP SAMPLES SUBMITTED:
PWS USES ORTHOPHOSPHATE, SILICA, OR CALCIUM INHIBITOR ______
SECTION III. WQP ANALYTICAL INFORMATION
PARAMETERS (LAB APPROVED)
Analyte Code / Name / Unit of Measurement
* required when using a corrosion control inhibitor
containing phosphate or silicate compounds / Sample Address: / Sample Address: / Sample Address: / Sample Address: / ANALYSIS METHOD
1925 pH
1996 Temperature (°C )
1927 Alkalinity (mg/L)
1064 Conductivity (µmho/cm)
1919 Calcium (mg/L)
1044 Orthophosphate*
1049 Silica*
1919 Calcium Carbonate*
SAMPLE INFORMATION
Collection Date
Collection Time
Laboratory Sample ID Number
ANALYSIS INFORMATION
Analysis Start Date
Analysis Start Time
Analysis End Date
Analysis End Time
SECTION IV. APPROVED LABORATORY INFORMATION
LABORATORY NAME: / LABORATORY ID #:
LABORATORY ADDRESS: / LAB PHONE #:
LAB CONTACT NAME: / SIGNATURE:
SECTION V. TCEQ REVIEW STATUS
ACCEPTED DISAPPROVED / INTERNAL TCEQ INITIALS AND DATE:
REVIEW COMMENTS:
INSTRUCTIONS FOR FILLING OUT THE LEAD AND COPPER WATER QUALITY PARAMETER REPORT FORM
(USE MORE THAN ONE FORM IF NEEDED)
SECTION I. PWS INFORMATION1. PWSID# TX: FILL IN THE PWS ID NUMBER
2. PWS NAME: FILL IN THE PWS NAME
3. PHONE #: FILL IN THE PWS CONTACT NUMBER
4. PWS TYPE: CHECK IF PWS IS COMMUNITY OR NTNC
5. POPULATION: CHECK APPLICABLE PWS POPULATION
6. PWS AUTHORIZED PERSON=CONTACT NAME, TITLE, DATE
7. PWS AUTHORIZED SIGNATURE
1. CHECK FOR WQP MONITORING SCHEDULE (INITIAL, ANNUAL, 3YR)
2. CHECK WHETHER PWS IS COMPLETING WQP SAMPLING DUE TO AN EXCEEDANCE
3. CHECK WHETHER THE SAMPLES ARE TAKEN IN DISTRIBUTION SYSTEM OR ENTRY POINTS TO THE DISTRIBUTION SYSTEM
4. WRITE IN HOW MANY DS SAMPLES WERE REQUIRED AND HOW MANY WERE TAKEN AND SUBMITTED TO TCEQ
5. WRITE IN HOW MANY EP SAMPLES WERE REQUIRED AND HOW MANY WERE TAKEN AND SUBMITTED TO TCEQ
6. CHECK WHETHER YOU USE CC TREATMENT OR NOT – WRITE IN WHAT TYPE
7. PWS COMMENTS TO TCEQ
1. SAMPLE LOCATION ADDRESS: FILL IN ADDRESS WHERE SAMPLED (REPRESENTATIVE SITES, USUALLY AT THE SAME TIME AND LOCATION AS BACTERIOLOGICAL SAMPLES)
2. FIELD MEASUREMENTS – SAMPLES TAKEN IN THE FIELD ARE pH AND TEMPERATURE. FILL IN THE AMOUNTS IN THE BOX BELOW THE LOCATION ADDRESS
1925 IS THE ANALYTICAL CONTAMINANT CODE FOR pH AND 1927 IS THE ANALYTICAL CONTAMINANT CODE FOR TEMPERATURE
THESE CAN BE DONE IN THE FIELD BY THE PWS DESIGNATED PERSON NO MORE THAN 15 MINUTES AFTER SAMPLE COLLECTION OR AT A LABORATORY.
3. PARAMETERS – SAMPLES TAKEN HERE ARE TO GO TO AN APPROVED LAB FOR ANALYSIS. THE APPROVED LAB WILL FILL IN THE AMOUNTS ALONG WITH THE ANALYSIS METHOD
ANALYTICAL CONTAMINANT CODES ARE LISTED ABOVE EACH ANALYTE 1927 = ALKALINITY, 1064 = CONDUCTIVITY, 1044 = ORTHOPOSPHATE, 1049 = SILICA, 1919 = CALCIUM
THE 1044, 1049, AND 1919 (AS CARBONATE) ARE ONLY ANALYZED IF THE PWS USES A CORROSION CONTROL INHIBITOR
4. LAB SAMPLE ID NUMBER: FILLED IN BY THE LAB
5. COLLECTION DATE: FILL IN DATE WHEN THE SAMPLE WAS COLLECTED
SECTION IV. APPROVED LABORATORY INFORMATION SECTION V. TCEQ REVIEW STATUS1. LABORATORY NAME: LAB TO FILL IN APPROVED LAB NAME 1. RESERVED FOR INTERNAL TCEQ USE
2. LABORATORY ID #: LAB TO FILL IN NUMBER FROM TCEQ
3. LABORATORY ADDRESS AND TELEPHONE NUMBER
4. LABORATORY CONTACT PERSON AND SIGNATURE
TEXAS COMMISSION ON ENVIRONMENTAL QUALITY
DRINKING WATER QUALITY / LEAD AND COPPER PROGRAM – MC 155
PO BOX 13087
AUSTIN, TEXAS 78711-3087
TCEQ-20679 (01-11-15)Page 1 of 2