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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Date Source(s) in use Treated water volume (GALLONS/DAY) Cylinder weight (LBS.) Chlorine used/Day (LBS.) UV Unit active (YES/NO) Quartz sleeve cleaned (YES/NO) Checked by (INITIALS) Intensity meter >70% Free chlorine residual at entry point (mg/l) Hypochlorite added to crock (GALLONS OR QUARTS) Gaseous Liquid TOTAL AVG CHLORINATION ULTRAVIOLET RADIATION/OTHER TREATMENTS Chlorine Mix Ratio = Date UV quartz sleeve last cleaned: Required Treatment Residual Level: Reported by: Title: NYSDOH Operator Certification Number: Signature: Date: Operator Grade Level: mg/l Date UV lamp replaced: quarts/gallons of % chlorine added to gallons of water in crock. Alarm activation: MM/YYYY MM/YYYY MM//DD/YY MM//DD/YY MM//DD/YY MM//DD/YY No Yes If “Yes,” date of activation: DOH-360CUV (01/10) Page 1 of 2 NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Water Supply Protection Water System Operation Report For Systems that Treat with Chlorine and/or Ultraviolet Radiation Public Water System Name: Reporting Month/Year: Date Report Submitted: County: Town, Village or City: Public Water System ID: NY Surface Ground GWUDI Purchase with subsequent chlorination Purchase w/out subsequent chlorination 4 log treatment required Source Water Type(s): ---PAGE BREAK--- Population Served: Number of microbiological monitoring samples required: Number of microbiological monitoring samples taken: Did a M&R violation occur? If “Yes,” check reason below: Actual number of samples is fewer than required Did not collect/analyze repeat sample Did not collect/analyze for E. coli for positive total coliform from routine / repeat sample Was triggered source water monitoring required? Did a MCL violation occur? If “Yes,” check reason(s) below (see also Part 5, Table 6 for Additional information). For systems collecting less than 40 samples per month: two or more of the samples (routine and/or repeat) are positive for total coliform total coliform MCL violation). For systems collecting 40 or more samples per month: more than 5% of the samples (routine and/or repeat) are positive for total coliform total coliform MCL violation). The original sample was E.coli positive and at least 1 repeat sample was positive for total coliform E.coli MCL violation). Reminder: System must collect a minimum of five routine microbiological monitoring samples during the month following a repeat sample collection unless waived (to minimum of one sample) in writing by the local health department. As required by 5-1.72, “Operation of a Public Water System,” a copy of this form shall be sent to your local health department by the 10th calendar day of the next reporting period. Sample Location Date of Sample Total Coliform Positive Free Chlorine Residual (mg/l) E. coli Positive Sample Type 1. ROUTINE 2. REPEAT 3. TRIGGERED Y N Y N Microbiological Samples and Free Chlorine Residual Sample collector(s): Name of NYSDOH Certified Laboratory: Did any MCL violation occur? If so, please describe: Did an emergency or low pressure problem occur? Did source water bypass an existing treatment process in the system? If so, please explain: Comments : DOH-360CUV (01/10) Page 2 of 2 Yes No Yes No Yes No