IFB 1185 Attachment 3 - Water System Operation Report.pdf

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Attached to
IFB 1185 NYS Certified Water Treatment Operator for Technical Services
Solicitation number
2122756
Issued by
Clinton County, Dutchess County, Monroe County, Oneida County, Orange County, Otsego County, Brookhaven CDP, New York

About this file

Written by GovTribe AI ·

This document is a New York State Department of Health (NYSDOH) Water System Operation Report form designed for public water systems that utilize chlorine and/or ultraviolet radiation treatment. The two-page form is specifically from the Bureau of Water Supply Protection and is intended to record daily and monthly operational data related to water treatment processes. The form requires detailed tracking of water treatment parameters including treated water volume, chlorination details (gaseous and liquid), ultraviolet radiation treatments, cylinder weights, chlorine usage, UV unit status, and quartz sleeve cleaning records.

The report includes sections for documenting microbiological sample testing, monitoring compliance, potential violations, and sample collection information. It requires operators to record the number of monitoring samples taken, whether any monitoring and reporting (M&R) or maximum contaminant level (MCL) violations occurred, and provides space for comments about emergency situations or treatment process bypasses. The form must be completed by a certified NYSDOH water system operator and submitted to the local health department by the 10th calendar day of the next reporting period, ensuring comprehensive documentation and oversight of water treatment system operations.

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Other files

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IFB 1185 Attachment 4 - Water Treatment Log.pdf PDF
IFB 1185 Attachment 5 - County Sampling Requirements per Facility.pdf PDF
IFB 1185 Q&A.pdf PDF
IFB 1185 Water Treatment Operators FINAL.pdf PDF
IFB 1185 Attachment 2 - References LOCKED.docx DOCX document
IFB 1185 OCFS-0910 Request For Bid Form FINAL.pdf PDF
IFB 1185 Attachment 6 - Annual Water Quality Report.pdf PDF
IFB 1185 Attachment 1 - Bidder's Certified Statements LOCKED.docx DOCX document

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Date Source(s) in use

Treated water volume

(GALLONS/DAY)

Cylinder weight

(LBS.)

Chlorine used/Day

(LBS.)

UV Unit active

(YES/NO)

Quartz sleeve cleaned

(YES/NO)

Checked by

(INITIALS)

Intensity meter >70%

Free chlorine residual at entry point

(mg/l)

Hypochlorite added to crock

(GALLONS OR QUARTS)

Gaseous Liquid

TOTAL

AVG

CHLORINATION ULTRAVIOLET RADIATION/OTHER TREATMENTS

Chlorine Mix Ratio =

Date UV quartz sleeve last cleaned:

Required Treatment Residual Level:

Reported by: Title:

NYSDOH Operator Certification Number:

Signature: Date: Operator Grade Level:

mg/l

Date UV lamp replaced:

quarts/gallons of % chlorine added to gallons of water in crock.

Alarm activation:

MM/YYYY MM/YYYY

MM//DD/YY MM//DD/YY

MM//DD/YY

MM//DD/YY

No Yes If “Yes,” date of activation:

DOH-360CUV (09/18) Page 1 of 2

NEW YORK STATE DEPARTMENT OF HEALTH

Bureau of Water Supply Protection

Water System Operation Report For Systems that Treat with Chlorine and/or Ultraviolet Radiation

Public Water System Name:

Reporting Month/Year: Date Report Submitted:

County: Town, Village or City:

Public Water System ID: NY

Surface Ground

GWUDI

Purchase with subsequent chlorination Purchase w/out subsequent chlorination 4 log treatment required

Source Water Type(s):

Population Served:

Number of microbiological monitoring samples required:

Number of microbiological monitoring samples taken:

Did a M&R violation occur?

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

Was triggered source water monitoring required?

Did a MCL violation occur?

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 unless waived (to minimum of one sample) in writing by the local health department.

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.

Sample Location Date of Sample

Total Coliform Positive

Free Chlorine Residual

(mg/l)

E. coli Positive

Sample Type

1. ROUTINE

2. REPEAT

3. TRIGGERED Y N Y N

Microbiological Samples and Free Chlorine Residual

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-360CUV (09/18) Page 2 of 2

Yes No

Yes No

Yes No

Public Water System Name:
NY:
County:
Town Village or City:
Reporting MonthYear:
Date Report Submitted:
Surface: Off
Ground: Off
GWUDI: Off
Purchase with subsequent chlorination: Off
Purchase wout subsequent chlorination: Off
4 log treatment required: Off
Sources in use1:
Treated water volume GALLONSDAY1:
Chlorine usedDay LBS1:
Hypochlorite added to crock GALLONS OR QUARTS1:
Free chlorine residual at entry point mgl1:
UV Unit active YESNO1:
Intensity meter 701:
Quartz sleeve cleaned YESNO1:
Checked by INITIALS1:
ULTRAVIOLET RADIATIONOTHER TREATMENTS1:
ULTRAVIOLET RADIATIONOTHER TREATMENTS1_2:
Sources in use2:
Treated water volume GALLONSDAY2:
Chlorine usedDay LBS2:
Hypochlorite added to crock GALLONS OR QUARTS2:
Free chlorine residual at entry point mgl2:
UV Unit active YESNO2:
Intensity meter 702:
Quartz sleeve cleaned YESNO2:
Checked by INITIALS2:
ULTRAVIOLET RADIATIONOTHER TREATMENTS2:
ULTRAVIOLET RADIATIONOTHER TREATMENTS2_2:
Sources in use3:
Treated water volume GALLONSDAY3:
Chlorine usedDay LBS3:
Hypochlorite added to crock GALLONS OR QUARTS3:
Free chlorine residual at entry point mgl3:
UV Unit active YESNO3:
Intensity meter 703:
Quartz sleeve cleaned YESNO3:
Checked by INITIALS3:
ULTRAVIOLET RADIATIONOTHER TREATMENTS3:
ULTRAVIOLET RADIATIONOTHER TREATMENTS3_2:
Sources in use4:
Treated water volume GALLONSDAY4:
Chlorine usedDay LBS4:
Hypochlorite added to crock GALLONS OR QUARTS4:
Free chlorine residual at entry point mgl4:
UV Unit active YESNO4:
Intensity meter 704:
Quartz sleeve cleaned YESNO4:
Checked by INITIALS4:
ULTRAVIOLET RADIATIONOTHER TREATMENTS4:
ULTRAVIOLET RADIATIONOTHER TREATMENTS4_2:
Sources in use5:
Treated water volume GALLONSDAY5:
Chlorine usedDay LBS5:
Hypochlorite added to crock GALLONS OR QUARTS5:
Free chlorine residual at entry point mgl5:
UV Unit active YESNO5:
Intensity meter 705:
Quartz sleeve cleaned YESNO5:
Checked by INITIALS5:
ULTRAVIOLET RADIATIONOTHER TREATMENTS5:
ULTRAVIOLET RADIATIONOTHER TREATMENTS5_2:
Sources in use6:
Treated water volume GALLONSDAY6:
Chlorine usedDay LBS6:
Hypochlorite added to crock GALLONS OR QUARTS6:
Free chlorine residual at entry point mgl6:
UV Unit active YESNO6:
Intensity meter 706:
Quartz sleeve cleaned YESNO6:
Checked by INITIALS6:
ULTRAVIOLET RADIATIONOTHER TREATMENTS6:
ULTRAVIOLET RADIATIONOTHER TREATMENTS6_2:
Sources in use7:
Treated water volume GALLONSDAY7:
Chlorine usedDay LBS7:
Hypochlorite added to crock GALLONS OR QUARTS7:
Free chlorine residual at entry point mgl7:
UV Unit active YESNO7:
Intensity meter 707:
Quartz sleeve cleaned YESNO7:
Checked by INITIALS7:
ULTRAVIOLET RADIATIONOTHER TREATMENTS7:
ULTRAVIOLET RADIATIONOTHER TREATMENTS7_2:
Sources in use8:
Treated water volume GALLONSDAY8:
Chlorine usedDay LBS8:
Hypochlorite added to crock GALLONS OR QUARTS8:
Free chlorine residual at entry point mgl8:
UV Unit active YESNO8:
Intensity meter 708:
Quartz sleeve cleaned YESNO8:
Checked by INITIALS8:
ULTRAVIOLET RADIATIONOTHER TREATMENTS8:
ULTRAVIOLET RADIATIONOTHER TREATMENTS8_2:
Sources in use9:
Treated water volume GALLONSDAY9:
Chlorine usedDay LBS9:
Hypochlorite added to crock GALLONS OR QUARTS9:
Free chlorine residual at entry point mgl9:
UV Unit active YESNO9:
Intensity meter 709:
Quartz sleeve cleaned YESNO9:
Checked by INITIALS9:
ULTRAVIOLET RADIATIONOTHER TREATMENTS9:
ULTRAVIOLET RADIATIONOTHER TREATMENTS9_2:
Sources in use10:
Treated water volume GALLONSDAY10:
Chlorine usedDay LBS10:
Hypochlorite added to crock GALLONS OR QUARTS10:
Free chlorine residual at entry point mgl10:
UV Unit active YESNO10:
Intensity meter 7010:
Quartz sleeve cleaned YESNO10:
Checked by INITIALS10:
ULTRAVIOLET RADIATIONOTHER TREATMENTS10:
ULTRAVIOLET RADIATIONOTHER TREATMENTS10_2:
Sources in use11:
Treated water volume GALLONSDAY11:
Chlorine usedDay LBS11:
Hypochlorite added to crock GALLONS OR QUARTS11:
Free chlorine residual at entry point mgl11:
UV Unit active YESNO11:
Intensity meter 7011:
Quartz sleeve cleaned YESNO11:
Checked by INITIALS11:
ULTRAVIOLET RADIATIONOTHER TREATMENTS11:
ULTRAVIOLET RADIATIONOTHER TREATMENTS11_2:
Sources in use12:
Treated water volume GALLONSDAY12:
Chlorine usedDay LBS12:
Hypochlorite added to crock GALLONS OR QUARTS12:
Free chlorine residual at entry point mgl12:
UV Unit active YESNO12:
Intensity meter 7012:
Quartz sleeve cleaned YESNO12:
Checked by INITIALS12:
ULTRAVIOLET RADIATIONOTHER TREATMENTS12:
ULTRAVIOLET RADIATIONOTHER TREATMENTS12_2:
Sources in use13:
Treated water volume GALLONSDAY13:
Chlorine usedDay LBS13:
Hypochlorite added to crock GALLONS OR QUARTS13:
Free chlorine residual at entry point mgl13:
UV Unit active YESNO13:
Intensity meter 7013:
Quartz sleeve cleaned YESNO13:
Checked by INITIALS13:
ULTRAVIOLET RADIATIONOTHER TREATMENTS13:
ULTRAVIOLET RADIATIONOTHER TREATMENTS13_2:
Sources in use14:
Treated water volume GALLONSDAY14:
Chlorine usedDay LBS14:
Hypochlorite added to crock GALLONS OR QUARTS14:
Free chlorine residual at entry point mgl14:
UV Unit active YESNO14:
Intensity meter 7014:
Quartz sleeve cleaned YESNO14:
Checked by INITIALS14:
ULTRAVIOLET RADIATIONOTHER TREATMENTS14:
ULTRAVIOLET RADIATIONOTHER TREATMENTS14_2:
Sources in use15:
Treated water volume GALLONSDAY15:
Chlorine usedDay LBS15:
Hypochlorite added to crock GALLONS OR QUARTS15:
Free chlorine residual at entry point mgl15:
UV Unit active YESNO15:
Intensity meter 7015:
Quartz sleeve cleaned YESNO15:
Checked by INITIALS15:
ULTRAVIOLET RADIATIONOTHER TREATMENTS15:
ULTRAVIOLET RADIATIONOTHER TREATMENTS15_2:
Sources in use16:
Treated water volume GALLONSDAY16:
Chlorine usedDay LBS16:
Hypochlorite added to crock GALLONS OR QUARTS16:
Free chlorine residual at entry point mgl16:
UV Unit active YESNO16:
Intensity meter 7016:
Quartz sleeve cleaned YESNO16:
Checked by INITIALS16:
ULTRAVIOLET RADIATIONOTHER TREATMENTS16:
ULTRAVIOLET RADIATIONOTHER TREATMENTS16_2:
Sources in use17:
Treated water volume GALLONSDAY17:
Chlorine usedDay LBS17:
Hypochlorite added to crock GALLONS OR QUARTS17:
Free chlorine residual at entry point mgl17:
UV Unit active YESNO17:
Intensity meter 7017:
Quartz sleeve cleaned YESNO17:
Checked by INITIALS17:
ULTRAVIOLET RADIATIONOTHER TREATMENTS17:
ULTRAVIOLET RADIATIONOTHER TREATMENTS17_2:
Sources in use18:
Treated water volume GALLONSDAY18:
Chlorine usedDay LBS18:
Hypochlorite added to crock GALLONS OR QUARTS18:
Free chlorine residual at entry point mgl18:
UV Unit active YESNO18:
Intensity meter 7018:
Quartz sleeve cleaned YESNO18:
Checked by INITIALS18:
ULTRAVIOLET RADIATIONOTHER TREATMENTS18:
ULTRAVIOLET RADIATIONOTHER TREATMENTS18_2:
Sources in use19:
Treated water volume GALLONSDAY19:
Chlorine usedDay LBS19:
Hypochlorite added to crock GALLONS OR QUARTS19:
Free chlorine residual at entry point mgl19:
UV Unit active YESNO19:
Intensity meter 7019:
Quartz sleeve cleaned YESNO19:
Checked by INITIALS19:
ULTRAVIOLET RADIATIONOTHER TREATMENTS19:
ULTRAVIOLET RADIATIONOTHER TREATMENTS19_2:
Sources in use20:
Treated water volume GALLONSDAY20:
Chlorine usedDay LBS20:
Hypochlorite added to crock GALLONS OR QUARTS20:
Free chlorine residual at entry point mgl20:
UV Unit active YESNO20:
Intensity meter 7020:
Quartz sleeve cleaned YESNO20:
Checked by INITIALS20:
ULTRAVIOLET RADIATIONOTHER TREATMENTS20:
ULTRAVIOLET RADIATIONOTHER TREATMENTS20_2:
Sources in use21:
Treated water volume GALLONSDAY21:
Chlorine usedDay LBS21:
Hypochlorite added to crock GALLONS OR QUARTS21:
Free chlorine residual at entry point mgl21:
UV Unit active YESNO21:
Intensity meter 7021:
Quartz sleeve cleaned YESNO21:
Checked by INITIALS21:
ULTRAVIOLET RADIATIONOTHER TREATMENTS21:
ULTRAVIOLET RADIATIONOTHER TREATMENTS21_2:
Sources in use22:
Treated water volume GALLONSDAY22:
Chlorine usedDay LBS22:
Hypochlorite added to crock GALLONS OR QUARTS22:
Free chlorine residual at entry point mgl22:
UV Unit active YESNO22:
Intensity meter 7022:
Quartz sleeve cleaned YESNO22:
Checked by INITIALS22:
ULTRAVIOLET RADIATIONOTHER TREATMENTS22:
ULTRAVIOLET RADIATIONOTHER TREATMENTS22_2:
Sources in use23:
Treated water volume GALLONSDAY23:
Chlorine usedDay LBS23:
Hypochlorite added to crock GALLONS OR QUARTS23:
Free chlorine residual at entry point mgl23:
UV Unit active YESNO23:
Intensity meter 7023:
Quartz sleeve cleaned YESNO23:
Checked by INITIALS23:
ULTRAVIOLET RADIATIONOTHER TREATMENTS23:
ULTRAVIOLET RADIATIONOTHER TREATMENTS23_2:
Sources in use24:
Treated water volume GALLONSDAY24:
Chlorine usedDay LBS24:
Hypochlorite added to crock GALLONS OR QUARTS24:
Free chlorine residual at entry point mgl24:
UV Unit active YESNO24:
Intensity meter 7024:
Quartz sleeve cleaned YESNO24:
Checked by INITIALS24:
ULTRAVIOLET RADIATIONOTHER TREATMENTS24:
ULTRAVIOLET RADIATIONOTHER TREATMENTS24_2:
Sources in use25:
Treated water volume GALLONSDAY25:
Chlorine usedDay LBS25:
Hypochlorite added to crock GALLONS OR QUARTS25:
Free chlorine residual at entry point mgl25:
UV Unit active YESNO25:
Intensity meter 7025:
Quartz sleeve cleaned YESNO25:
Checked by INITIALS25:
ULTRAVIOLET RADIATIONOTHER TREATMENTS25:
ULTRAVIOLET RADIATIONOTHER TREATMENTS25_2:
Sources in use26:
Treated water volume GALLONSDAY26:
Chlorine usedDay LBS26:
Hypochlorite added to crock GALLONS OR QUARTS26:
Free chlorine residual at entry point mgl26:
UV Unit active YESNO26:
Intensity meter 7026:
Quartz sleeve cleaned YESNO26:
Checked by INITIALS26:
ULTRAVIOLET RADIATIONOTHER TREATMENTS26:
ULTRAVIOLET RADIATIONOTHER TREATMENTS26_2:
Sources in use27:
Treated water volume GALLONSDAY27:
Chlorine usedDay LBS27:
Hypochlorite added to crock GALLONS OR QUARTS27:
Free chlorine residual at entry point mgl27:
UV Unit active YESNO27:
Intensity meter 7027:
Quartz sleeve cleaned YESNO27:
Checked by INITIALS27:
ULTRAVIOLET RADIATIONOTHER TREATMENTS27:
ULTRAVIOLET RADIATIONOTHER TREATMENTS27_2:
Sources in use28:
Treated water volume GALLONSDAY28:
Chlorine usedDay LBS28:
Hypochlorite added to crock GALLONS OR QUARTS28:
Free chlorine residual at entry point mgl28:
UV Unit active YESNO28:
Intensity meter 7028:
Quartz sleeve cleaned YESNO28:
Checked by INITIALS28:
ULTRAVIOLET RADIATIONOTHER TREATMENTS28:
ULTRAVIOLET RADIATIONOTHER TREATMENTS28_2:
Sources in use29:
Treated water volume GALLONSDAY29:
Chlorine usedDay LBS29:
Hypochlorite added to crock GALLONS OR QUARTS29:
Free chlorine residual at entry point mgl29:
UV Unit active YESNO29:
Intensity meter 7029:
Quartz sleeve cleaned YESNO29:
Checked by INITIALS29:
ULTRAVIOLET RADIATIONOTHER TREATMENTS29:
ULTRAVIOLET RADIATIONOTHER TREATMENTS29_2:
Sources in use30:
Treated water volume GALLONSDAY30:
Chlorine usedDay LBS30:
Hypochlorite added to crock GALLONS OR QUARTS30:
Free chlorine residual at entry point mgl30:
UV Unit active YESNO30:
Intensity meter 7030:
Quartz sleeve cleaned YESNO30:
Checked by INITIALS30:
ULTRAVIOLET RADIATIONOTHER TREATMENTS30:
ULTRAVIOLET RADIATIONOTHER TREATMENTS30_2:
Sources in use31:
Treated water volume GALLONSDAY31:
Chlorine usedDay LBS31:
Hypochlorite added to crock GALLONS OR QUARTS31:
Free chlorine residual at entry point mgl31:
UV Unit active YESNO31:
Intensity meter 7031:
Quartz sleeve cleaned YESNO31:
Checked by INITIALS31:
ULTRAVIOLET RADIATIONOTHER TREATMENTS31:
ULTRAVIOLET RADIATIONOTHER TREATMENTS31_2:
Treated water volume GALLONSDAYTOTAL:
Chlorine usedDay LBSTOTAL:
Hypochlorite added to crock GALLONS OR QUARTSTOTAL:
UV Unit active YESNOTOTAL:
Intensity meter 70TOTAL:
Quartz sleeve cleaned YESNOTOTAL:
Checked by INITIALSTOTAL:
ULTRAVIOLET RADIATIONOTHER TREATMENTSTOTAL:
ULTRAVIOLET RADIATIONOTHER TREATMENTSTOTAL_2:
Treated water volume GALLONSDAYAVG:
Chlorine usedDay LBSAVG:
Hypochlorite added to crock GALLONS OR QUARTSAVG:
Free chlorine residual at entry point mglAVG:
UV Unit active YESNOAVG:
Intensity meter 70AVG:
Quartz sleeve cleaned YESNOAVG:
Checked by INITIALSAVG:
ULTRAVIOLET RADIATIONOTHER TREATMENTSAVG:
ULTRAVIOLET RADIATIONOTHER TREATMENTSAVG_2:
Chlorine Mix Ratio:
quartsgallons of:
chlorine added to:
Date UV quartz sleeve last cleaned:
Date UV lamp replaced:
Alarm activation: No
If Yes date of activation:
Required Treatment Residual Level:
Reported by:
Title:
Certification Number:
Date:
Operator Grade Level:
Population Served:
Number of microbiological monitoring samples required:
Number of microbiological monitoring samples taken:
Sample LocationRow1:
Date of SampleRow1:
Sample Type 1 ROUTINE 2 REPEAT 3 TRIGGEREDRow1:
Free Chlorine Residual mgl:
Sample LocationRow2:
Date of SampleRow2:
Sample Type 1 ROUTINE 2 REPEAT 3 TRIGGEREDRow2:
Free Chlorine Residual mgl_2:
Sample LocationRow3:
Date of SampleRow3:
Sample Type 1 ROUTINE 2 REPEAT 3 TRIGGEREDRow3:
Free Chlorine Residual mgl_3:
Sample LocationRow4:
Date of SampleRow4:
Sample Type 1 ROUTINE 2 REPEAT 3 TRIGGEREDRow4:
Free Chlorine Residual mgl_4:
Actual number of samples is fewer than required: Off
Did not collectanalyze repeat sample: Off
Did not collectanalyze for E coli for positive total coliform: Off
Sample LocationRow5:
Date of SampleRow5:
Sample Type 1 ROUTINE 2 REPEAT 3 TRIGGEREDRow5:
Free Chlorine Residual mgl_5:
Sample LocationRow6:
Date of SampleRow6:
Sample Type 1 ROUTINE 2 REPEAT 3 TRIGGEREDRow6:
Free Chlorine Residual mgl_6:
Sample LocationRow7:
Date of SampleRow7:
Sample Type 1 ROUTINE 2 REPEAT 3 TRIGGEREDRow7:
Free Chlorine Residual mgl_7:
Sample LocationRow8:
Date of SampleRow8:
Sample Type 1 ROUTINE 2 REPEAT 3 TRIGGEREDRow8:
Free Chlorine Residual mgl_8:
Sample LocationRow9:
Date of SampleRow9:
Sample Type 1 ROUTINE 2 REPEAT 3 TRIGGEREDRow9:
Free Chlorine Residual mgl_9:
For systems collecting less than 40 samples per month two: Off
For systems collecting 40 or more samples per month more: Off
The original sample was Ecoli positive and at least 1 repeat: Off
Sample LocationRow10:
Date of SampleRow10:
Sample Type 1 ROUTINE 2 REPEAT 3 TRIGGEREDRow10:
Free Chlorine Residual mgl_10:
Sample LocationRow11:
Date of SampleRow11:
Sample Type 1 ROUTINE 2 REPEAT 3 TRIGGEREDRow11:
Free Chlorine Residual mgl_11:
Sample LocationRow12:
Date of SampleRow12:
Sample Type 1 ROUTINE 2 REPEAT 3 TRIGGEREDRow12:
Free Chlorine Residual mgl_12:
Sample LocationRow13:
Date of SampleRow13:
Sample Type 1 ROUTINE 2 REPEAT 3 TRIGGEREDRow13:
Free Chlorine Residual mgl_13:
Sample LocationRow14:
Date of SampleRow14:
Sample Type 1 ROUTINE 2 REPEAT 3 TRIGGEREDRow14:
Free Chlorine Residual mgl_14:
Sample LocationRow15:
Date of SampleRow15:
Sample Type 1 ROUTINE 2 REPEAT 3 TRIGGEREDRow15:
Free Chlorine Residual mgl_15:
Sample LocationRow16:
Date of SampleRow16:
Sample Type 1 ROUTINE 2 REPEAT 3 TRIGGEREDRow16:
Free Chlorine Residual mgl_16:
Sample LocationRow17:
Date of SampleRow17:
Sample Type 1 ROUTINE 2 REPEAT 3 TRIGGEREDRow17:
Free Chlorine Residual mgl_17:
Sample LocationRow18:
Date of SampleRow18:
Sample Type 1 ROUTINE 2 REPEAT 3 TRIGGEREDRow18:
Sample collectors:
Name of NYSDOH Certified Laboratory:
cylwt1:
cylwt2:
cylwt3:
other1:
other2:
cylwt4:
cylwt5:
cylwt6:
cylwt7:
cylwt8:
cylwt9:
cylwt10:
cylwt11:
cylwt12:
cylwt13:
cylwt14:
cylwt15:
cylwt16:
cylwt17:
cylwt18:
cylwt19:
cylwt20:
cylwt21:
cylwt22:
cylwt23:
cylwt24:
cylwt25:
cylwt26:
cylwt27:
cylwt28:
cylwt29:
cylwt30:
cylwt31:
Check Box5: Off
Check Box6: Off
Check Box7: Off
Check Box8: Off
Check Box9: Off
Check Box10: Off
Check Box11: Off
Check Box12: Off
Check Box13: Off
Check Box14: Off
Check Box15: Off
Check Box16: Off
Check Box17: Off
Check Box18: Off
Check Box19: Off
Check Box20: Off
Check Box21: Off
Check Box22: Off
Check Box23: Off
Check Box24: Off
Check Box25: Off
Check Box26: Off
Check Box27: Off
Check Box28: Off
Check Box29: Off
Check Box30: Off
Check Box31: Off
Check Box32: Off
Check Box33: Off
Check Box34: Off
Check Box35: Off
Check Box36: Off
Check Box37: Off
Check Box38: Off
Check Box39: Off
Check Box40: Off
Check Box41: Off
Check Box42: Off
Check Box43: Off
Check Box44: Off
Check Box45: Off
Check Box46: Off
Check Box47: Off
Check Box48: Off
Check Box49: Off
Check Box50: Off
Check Box51: Off
Check Box52: Off
Check Box53: Off
Check Box54: Off
Check Box55: Off
Check Box56: Off
Check Box57: Off
Check Box58: Off
Check Box59: Off
Check Box60: Off
Check Box61: Off
Check Box62: Off
Check Box63: Off
Check Box64: Off
Check Box65: Off
Check Box66: Off
Check Box67: Off
Check Box68: Off
Check Box69: Off
Check Box70: Off
Check Box71: Off
Check Box72: Off
Check Box73: Off
Check Box74: Off
Check Box75: Off
Check Box76: Off
Text6:
Text7:
Text8:
n1: Off
y1: Off
y2: Off
n2: Off
y3: Off
n3: Off
Free Chlorine Residual mgl_18:

File details come from the government source that posted it. Updated .