Dep Form 62 555 900 6 – Fill Out and Use This PDF

MONTHLY OPERATION REPORT FOR CONSECUTIVE SYSTEMS THAT RECEIVE PURCHASED FINISHED WATER

FROM A SUBPART H SYSTEM

See Page 2 for Instructions.

I. General Water System Information for the Month/Year of:

System Name:						PWS Identification Number:
System Type:	Community	Non-Transient Non-Community	Transient Non-Community
Number of Service Connections at End of Month:					Total Population Served at End of Month:
System Owner:
Contact Person:					Contact Person’s Title:
Contact Person’s Mailing Address:				City:		State:	Zip Code:
Contact Person’s E-Mail Address:					Contact Person’s Telephone Number:

I, the undersigned lead/chief operator or authorized representative of this consecutive system, certify that the information provided in this report is true and accurate to the best of my knowledge and belief.

Signature and Date

Printed or Typed Name

License Number or Title

II. Daily Distribution System Disinfectant Residual Data for the Month/Year of:

Type of Disinfectant Residual Maintained in Distribution System:

Free Chlorine

Combined Chlorine (Chloramines)

b = No. of Sites

c = No. of Sites

d = No. of Sites

e = No. of Sites

b = No. of Sites

c = No. of Sites

d = No. of Sites

e = No. of Sites

a = No. of Sites

Where

Where

Where

Where

a = No. of Sites

Where

Where

Where

Where

Where

Disinfectant

Disinfectant

Disinfectant

Disinfectant

Where

Disinfectant

Disinfectant

Disinfectant

Disinfectant

Day of

Disinfectant

Residual Not

Residual Not

Residual Not

Residual Not

Day of

Disinfectant

Residual Not

Residual Not

Residual Not

Residual Not

the

Residual Was

Measured but

Detected and HPC

Detected and HPC

Measured and

the

Residual Was

Measured but

Detected and HPC

Detected and HPC

Measured and

Month

Measured

HPC Measured

Not Measured

> 500/mL

HPC > 500/mL

Month

Measured

HPC Measured

Not Measured

> 500/mL

HPC > 500/mL

1

17

2

18

3

19

4

20

5

10

6

22

7

23

8

24

9

25

10

26

11

27

12

28

13

29

14

30

15

31

16

Total

V = percentage of samples in which disinfectant residual is undetectable = (c+d+e)/(a+b) x 100 =

%

For previous month, V =

%

MONTHLY OPERATION REPORT FOR CONSECUTIVE SYSTEMS THAT RECEIVE PURCHASED FINISHED WATER

ORIGINATING FROM A SUBPART H SYSTEM

INSTRUCTIONS: This form shall be completed and submitted by consecutive systems that receive purchased finished water originating from a subpart H system. WITHIN TEN DAYS AFTER THE END OF EACH MONTH, complete this form and submit it to the appropriate Department of Environmental Protection District Office or appropriate Approved County Health Department. All information provided on this form shall be typed or printed in ink.

The following specific instructions are for the table in Part II of this Form.

Residual disinfectant measurements shall be taken in the distribution system at the same sites where, and at the same times when, total coliform samples are taken. Additional residual disinfectant measurements and/or heterotrophic plate count (HPC) measurements may be taken in the distribution system at other sites and/or at other times. For each day that residual disinfectant measurements and/or HPC measurements are taken in the distribution system, enter the following information: (a) the total number of sites where the disinfectant residual was measured; (b) the total number of sites where the disinfectant residual was not measured but HPC was measured; (c) the total number of sites where the disinfectant residual was measured but not detected and HPC was not measured; (d) the total number of sites where the disinfectant residual was measured but not detected and HPC was greater than 500/mL; and (e) the total number of sites where the disinfectant residual was not measured and HPC was greater than 500/mL. Compute and enter the totals for a, b, c, d, and e for the month. Compute and enter V for the month. In addition, enter V for the previous month.