"Monthly Operating Report Form for Population Over 3,300" - Mississippi

Monthly Operating Report Form for Population Over 3,300 is a legal document that was released by the Mississippi Department of Health - a government authority operating within Mississippi.

Form Details:

  • Released on October 29, 2009;
  • The latest edition currently provided by the Mississippi Department of Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Mississippi Department of Health.

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Download "Monthly Operating Report Form for Population Over 3,300" - Mississippi

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MONTHLY OPERATING REPORT for Population >3,300
Month/Year
Entry point or well number:
Required Minimum Cl (mg/l):
Lowest measured free
chlorine concentration
Duration of
(mg/l) with pump
low chlorine
Date
running
(hrs)
Initials
COMMENTS
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
Did continuous monitoring equipment fail at any time this reporting month?
If so, were grab samples collected every four hours until the continuous monitoring equipment
was returned to service?
(Attach grab sample results to this form)
Date continuous monitoring equipment failed:
Date it was returned to service:
Note: If the chlorine monitor fails, but the well is still running, then manual grab samples must be collected
every 4 hours, AND the monitor must be repaired or replaced within 14 days to avoid a Monitoring Violation.
Note: If the "lowest measured free chlorine concentration (mg/l) with pump running" is less than the Required
Minimum, then "Duration of low chlorine" must be less than 4 hrs to avoid a Treatment Technique Violation.
Do not submit to MSDH unless requested.
ver. 10/29/2009
MONTHLY OPERATING REPORT for Population >3,300
Month/Year
Entry point or well number:
Required Minimum Cl (mg/l):
Lowest measured free
chlorine concentration
Duration of
(mg/l) with pump
low chlorine
Date
running
(hrs)
Initials
COMMENTS
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
Did continuous monitoring equipment fail at any time this reporting month?
If so, were grab samples collected every four hours until the continuous monitoring equipment
was returned to service?
(Attach grab sample results to this form)
Date continuous monitoring equipment failed:
Date it was returned to service:
Note: If the chlorine monitor fails, but the well is still running, then manual grab samples must be collected
every 4 hours, AND the monitor must be repaired or replaced within 14 days to avoid a Monitoring Violation.
Note: If the "lowest measured free chlorine concentration (mg/l) with pump running" is less than the Required
Minimum, then "Duration of low chlorine" must be less than 4 hrs to avoid a Treatment Technique Violation.
Do not submit to MSDH unless requested.
ver. 10/29/2009