Exhibit F_NYSDOH Form DOH-360 (Water System Operation Report).pdf

New York State Department of Health WATER SYSTEM OPERATION REPORT Bureau of Water Supply Protection Microbiological Sample Results

Chlorination Other Treatments / Readings Gaseous Liquid

DATE Source(s) in use

Treated water volume

(1,000 gallons/day) Cylinder weight (lbs.)

Chlorine used per day (lbs.)

Hypochlorite added to crock (gallons or quarts)

Free chlorine residual at entry point

(mg/l)

TOTAL

AVG.

Source Water Type (s)

Surface Ground GWUDI

Purchase with subsequent chlorination

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

Purchase w/out subsequent chlorination

Public Water System ID

NY ___ ___ ___ ___ ___ ___ ___

County Town, Village or City

Chlorine Mix Ratio = __________________________ quarts/gallons of ________________________ % chlorine added to _____________________gallons of water in crock.

Reported by:____________________________________ Title: ____________________________ NYSDOH Operator Certification Number: _______________________

Signature: _____________________________________________________ Date: ___________________________ Operator Grade Level: ________________________

DOH-360 (02/2005) Page 1 of 2

Microbiological Samples and Free Chlorine Residual

Sample Location

Date of

Type

1.Routine

2. Repeat

Total Coliform Positive

E.coli Positive

Free

Chlorine Residual

(mg/l)

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

Population Served:__________________________

Number of microbiological monitoring samples required:_______

Number of microbiological monitoring samples taken: _________

Did an M&R violation occur? Yes No If “Yes,” check reason (s) 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 (5) 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

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-360 (02/2005) Page 2 of 2