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New York State Department of Health WATER SYSTEM OPERATION REPORT Public Water System Name Reporting Month/Year 2 0 M M Y Y Y Y Date Report Submitted 2 0 M M D D Y Y Y Y Source Water Type Surface Ground GWUDI Purchase with subsequent chlorination Purchase w/out subsequent chlorination Public Water System ID NY County Cortland Town, Village or City Bureau of Water Supply Protection Microbiological Sample Results DATE Source(s) in use Treated water volume (1,000 gallons/day) Chlorination Other Treatments / Readings Gaseous Liquid Free chlorine residual at entry point (mg/l) Cylinder weight (lbs.) Chlorine used per day (lbs.) Hypochlorite added to crock (gallons or quarts) 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 TOTAL AVG. Chlorine Mix Ratio = quarts/gallons of % chlorine added to of water in crock. Reported Title: NYSDOH Operator Certification Number: Signature: Date: Operator Grade Level: DOH-360 (02/05) Page 1 of 2 Microbiological Samples and Free Chlorine Residual Sample Location te mple Sample Type 1.Routine 2. Repeat Total Coliform Positive E.coli Positive Free Chlorine Residual (mg/l) Population Number of microbiological monitoring samples required:_______ Number of microbiological monitoring samples taken: Did an M&R violation occur? Yes□ No□ 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 Did an MCL violation occur? Yes□ No□ 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. 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. YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO Sample Collector(s): Name of NYSDOH Certified Laboratory: Did any MCL violation occur? If so, please describe: ---PAGE BREAK--- Did an emergency or low pressure problem occur? Did source water bypass an existing treatment process in the system? If so, please explain: DOH-360 (02/05) Page 2 of 2 I:\Environmental\Environm\WPDATA\water\PUBLICwatersupplies\dohforms\360.doc