DPH Fluoride Form A "Massachusetts Department of Public Health Daily Fluoridation Report" - Massachusetts

What Is DPH Fluoride Form A?

This is a legal form that was released by the Massachusetts Department of Environmental Protection - a government authority operating within Massachusetts. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on June 1, 2015;
  • The latest edition provided by the Massachusetts Department of Environmental Protection;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DPH Fluoride Form A by clicking the link below or browse more documents and templates provided by the Massachusetts Department of Environmental Protection.

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Download DPH Fluoride Form A "Massachusetts Department of Public Health Daily Fluoridation Report" - Massachusetts

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MASS/DEPARTMENT OF PUBLIC HEALTH DAILY FLUORIDATION REPORT
DPH-FL-A (Daily)
Month of ____Year of _____Page __ of ___(
Use the same form daily for one month for each source or manifolded or combined sources)
Section I. PWS INFORMATION:
1. PWS Name:
________________________ 2. PWS ID# :
_______ 3. City/Town or District:
___________________
4. Source(s) Fluoridated/MassDEP Source Code/Location ID:
______________________________
5. Is the Source(s) Manifolded? Yes
or No
6. List the location or Mass DEP location ID# for the daily sample:
_______
Section II. PWS CHEMICAL USE INFORMATION:
1. Type of fluoride used: NaF
Na
SiF
H
SiF
.
2
6
2
6
2. What is the purity of the fluoride compound?
____%. (From shipping container or hydrometer test rounded to nearest unit).
3. Are all fluoride-metering pumps protected by two (2) operating anti-siphon (back-pressure) valves? Yes
No
4. Was each anti-siphon valve disassembled and inspected in the last 12 months? Yes
Date
or No
Explain:
_______
5. Was the fluoride test meter calibrated each day before use? (See Note 2) Yes
or No
Explain:
______________________
6. Do you require on site technical assistance? Yes
or No
If yes, explain:
________________________________________
Section III. DAILY RESULT
1
DAYS
Gallons of
Amt.
Saturator
Calculated
Results of
Name of tester and Comments
Fluoride
Volume of Make
Fluoride Ion
Fluoride Test
E.g. Reason(s) for not fluoridating or sampling.
of the
Water Treated
2,3
(lbs)
Up Water Added
Dosage (ppm)
Added
by PWS (ppm)
(To nearest 1,000 gals)
month
Changes in product or batch mixing day etc.
Gals
or Cu Ft
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
If you use a Saturator: Calculated Monthly
Fluoride Ion Dosage ____________ ppm
Average
Notes: 1) If you use a Saturator you must calculate a monthly fluoride ion dosage based on pounds used.
2) If you use a Mass. certified lab. for daily sampling, attach a copy of your Mass. approved lab analytical report form to this report.
3) All pumping fluoridated sources MUST be tested daily for fluoride at the entry point to the distribution system or after the point of fluoride application.
4) The optimal fluoride level is 0.7 mg/L. 5) Report all Fluoride results to the nearest tenth.
6) For Fluoride issues that require reporting, notify DPH at 617-624-5573 AND MassDEP Drinking Water Program Regional Office or 617-292-5770
I certify under penalty of law that I am the person authorized to fill out this form and the information contained herein is true, accurate and complete to the best of my
knowledge and belief.
Name of PWS certified operator or responsible party:
________________Signature: ___________________ Date:
____
Phone #:
__________________Fax#:
____________________ Email address:
______________________________
Section IV: DPH USE: Date received
___________ Comments:
______________________________________________
th
PWSs approved by MassDEP for Fluoridation treatment must return all applicable pages (A, B &C) of this report form by the 10
day following the
th
reporting month to: MassDPH, 250 Washington Street-5
floor, Boston, MA 02108. Attention: Office of Oral Health
Fluoride
DPH
Form A 6-2015
MASS/DEPARTMENT OF PUBLIC HEALTH DAILY FLUORIDATION REPORT
DPH-FL-A (Daily)
Month of ____Year of _____Page __ of ___(
Use the same form daily for one month for each source or manifolded or combined sources)
Section I. PWS INFORMATION:
1. PWS Name:
________________________ 2. PWS ID# :
_______ 3. City/Town or District:
___________________
4. Source(s) Fluoridated/MassDEP Source Code/Location ID:
______________________________
5. Is the Source(s) Manifolded? Yes
or No
6. List the location or Mass DEP location ID# for the daily sample:
_______
Section II. PWS CHEMICAL USE INFORMATION:
1. Type of fluoride used: NaF
Na
SiF
H
SiF
.
2
6
2
6
2. What is the purity of the fluoride compound?
____%. (From shipping container or hydrometer test rounded to nearest unit).
3. Are all fluoride-metering pumps protected by two (2) operating anti-siphon (back-pressure) valves? Yes
No
4. Was each anti-siphon valve disassembled and inspected in the last 12 months? Yes
Date
or No
Explain:
_______
5. Was the fluoride test meter calibrated each day before use? (See Note 2) Yes
or No
Explain:
______________________
6. Do you require on site technical assistance? Yes
or No
If yes, explain:
________________________________________
Section III. DAILY RESULT
1
DAYS
Gallons of
Amt.
Saturator
Calculated
Results of
Name of tester and Comments
Fluoride
Volume of Make
Fluoride Ion
Fluoride Test
E.g. Reason(s) for not fluoridating or sampling.
of the
Water Treated
2,3
(lbs)
Up Water Added
Dosage (ppm)
Added
by PWS (ppm)
(To nearest 1,000 gals)
month
Changes in product or batch mixing day etc.
Gals
or Cu Ft
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
If you use a Saturator: Calculated Monthly
Fluoride Ion Dosage ____________ ppm
Average
Notes: 1) If you use a Saturator you must calculate a monthly fluoride ion dosage based on pounds used.
2) If you use a Mass. certified lab. for daily sampling, attach a copy of your Mass. approved lab analytical report form to this report.
3) All pumping fluoridated sources MUST be tested daily for fluoride at the entry point to the distribution system or after the point of fluoride application.
4) The optimal fluoride level is 0.7 mg/L. 5) Report all Fluoride results to the nearest tenth.
6) For Fluoride issues that require reporting, notify DPH at 617-624-5573 AND MassDEP Drinking Water Program Regional Office or 617-292-5770
I certify under penalty of law that I am the person authorized to fill out this form and the information contained herein is true, accurate and complete to the best of my
knowledge and belief.
Name of PWS certified operator or responsible party:
________________Signature: ___________________ Date:
____
Phone #:
__________________Fax#:
____________________ Email address:
______________________________
Section IV: DPH USE: Date received
___________ Comments:
______________________________________________
th
PWSs approved by MassDEP for Fluoridation treatment must return all applicable pages (A, B &C) of this report form by the 10
day following the
th
reporting month to: MassDPH, 250 Washington Street-5
floor, Boston, MA 02108. Attention: Office of Oral Health
Fluoride
DPH
Form A 6-2015

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