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Water Systems Operation Report For Ultra-Violet Disinfection Systems Only Instructions: Complete form and submit to the Cortland County Health Department within 10 days of the close of the reporting month. Name of Public Water System Program Code Federal ID Number Reporting Month/Year Location V, T) Cortlandville County: Cortland Source of Supply: Drilled Well Dug Well Other If Surface, is filtration provided? Yes No Did an emergency occur in any part of the water system? Yes No DATE Meter Reading Is UV Light working ? Intensity Meter Level Checked by: Time: Sampling Information 1 Population Served 2 3 Number of required routine samples per quarter.__ 4 5 Number of actual routine samples 6 7 8 Does an M&AR violation exist? Yes No 9 10 If yes, check reason(s) below: 11 12 Actual number of samples fewer than required. 13 14 Failure to analyze for e.coli if there was a positive result for total coliform from routine, repeat or high turbidity sample. 15 Failure to analyze repeat samples. 16 17 Does an MCL violation exist? Yes No 18 19 20 Maintenance Information 21 Was the quartz sleeve cleaned? Yes No 22 23 If Yes, please give date 24 Annual Bulb Replacement Date 25 26 Does System have automatic alarm to indicate light failure? Yes No 27 Did alarm activate during reporting period? Yes No 28 If so, what days? 29 30 31 What action was taken to remedy system failure? Reported by Date Title Signature ---PAGE BREAK--- Distribution System Analytical Results Sampling Location Date of Sample Sample Type Total Coliform Positive E.coli Positive * 1 = Routine Sample 2 = Repeat Sample Comments / Remarks I:\Environmental\Environm\WPDATA\water\PUBLICwatersupplies\dohforms\cortland county uv facilities\uv operation report.doc