SOURCE DISINFECTION TREATMENT PLANT REPORT FORM Water System Name: Month/Year: County: ID#: Report Submitted by: Treatment Plant #: Source(s)#: Operator Certification #: Requirements: Telephone #: Maximum flow rate: gpm Signature: Cl2 Residual: mg/L at entry point and mg/L in distribution Monitoring requirement: days per week Water Chlorine Solution Production Treated Water Quality Used Gallons or ft3 Tank Volume Troubleshooting Notes Cl2 Distribution Source Meter Level Used Distribution Also record additional Sampler Date Residual @ Cl2 Residual Reading Sample Location residual readings following a Initials Entry (mg/L) (mg/L) low or zero residual reading 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 Total number of measurements collected Max Min Water Treatment Summary (completed by operator) Send report by the 10th of the following month to your Number of days treatment plant produced water: _____ Regional Office. See instructions Number of days entry point free chlorine residual fell below minimum residual: _____ page. Number of days distribution free chlorine residual fell below minimum residual: _____
SOURCE DISINFECTION TREATMENT PLANT REPORT FORM Water System Name: Month/Year: County: ID#: Report Submitted by: Treatment Plant #: Source(s)#: Operator Certification #: Requirements: Maximum flow rate: gpm Cl2 Residual: mg/L at entry point and mg/L in distribution Monitoring requirement: days per week Telephone #: Signature: Water Production Gallons or ft3 Chlorine Solution Used Treated Water Quality Date Source Meter Reading Tank Level Volume Used Cl2 Residual @ Entry (mg/L) Distribution Cl2 Residual (mg/L) Distribution Sample Location Troubleshooting Notes Also record additional residual readings following a low or zero residual reading Sampler Initials 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 Total number of measurements collected Max Min Send report by the 10th of the following month to your Regional Office. See instructions page. Water Treatment Summary (completed by operator) Number of days treatment plant produced water: _____ Number of days entry point free chlorine residual fell below minimum residual: _____ Number of days distribution free chlorine residual fell below minimum residual: _____
331-430.docx