DOH Form 331-497 "Fluoridation Monthly Operations Report Form" - Washington

What Is DOH Form 331-497?

This is a legal form that was released by the Washington State Department of Health - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2014;
  • The latest edition provided by the Washington State Department of Health;
  • 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 DOH Form 331-497 by clicking the link below or browse more documents and templates provided by the Washington State Department of Health.

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Download DOH Form 331-497 "Fluoridation Monthly Operations Report Form" - Washington

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Fluoridation Monthly Operations Report Form
DOH Form 331-497
Dec. 2014
Fluorosilicic Acid / Sodium Fluorosilicate
System Name: __________________________________________
System ID No: ______________________________________
FIP No: ________________________________________________
Month/Year: _______________________________________
Contact Person: _________________________________________
Telephone No: _________________________________
The Department of Health supports water
Water Production
Fluoride Additive
Monitoring
fluoridation as a sound population-based public
Meter
Volume
Total
Calculated
Field Test
Date
Reading
Treated
Remaining
Quantity Used
Dosage
Result*
health measure, and supports communities in
(MG)
(MG)
(gals) or (lbs) (gals) or (lbs)
(mg/L)
(mg/L)
their efforts to maintain and fluoridate
Prev.
community water supplies.
1
2
Raw Water Data:
_____________________
3
Date of last sample:
__________________
mg/L
4
Lab result:
5
6
Fluoride Additive Data:
7
Fluorosilicic
Sodium Fluorosilicate
8
Manufacturer: ___________________________________
9
Is product ANSI-NSF Standard 60 approved?
Yes
%
10
P
_________________
ercent strength of acid used:
2
S
_______________ g/cm
11
pecific Gravity (SG) of acid:
12
13
Testing and Monitoring:
14
*Instrument used in Field Testing (make/model):
15
__________________________________________________
16
Method used (check one):
SPADNS
Electrode
17
Weekly Instrument Calibration:
18
19
Date
Standard mg/L
Result mg/L
20
21
22
23
24
25
26
Date Split Sample Taken: _______________________
27
28
Process Interruptions (date/time):
29
30
1st Start:
31
End:
Total
2nd Start:
Min
End:
Max
3rd Start:
Avg
End:
Count Total
Explain cause and corrective actions taken for
Count within range
interruption(s) on back of page.
Percent within range
Please send your report to us by the 10th day of the following month.
Certified Operator Signature: ______________________________________________________
Date: ___________________________
Washington Certification No.: ________________________________________________
For people with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-525-0127
(TDD/TTY call 711).
Fluoridation Monthly Operations Report Form
DOH Form 331-497
Dec. 2014
Fluorosilicic Acid / Sodium Fluorosilicate
System Name: __________________________________________
System ID No: ______________________________________
FIP No: ________________________________________________
Month/Year: _______________________________________
Contact Person: _________________________________________
Telephone No: _________________________________
The Department of Health supports water
Water Production
Fluoride Additive
Monitoring
fluoridation as a sound population-based public
Meter
Volume
Total
Calculated
Field Test
Date
Reading
Treated
Remaining
Quantity Used
Dosage
Result*
health measure, and supports communities in
(MG)
(MG)
(gals) or (lbs) (gals) or (lbs)
(mg/L)
(mg/L)
their efforts to maintain and fluoridate
Prev.
community water supplies.
1
2
Raw Water Data:
_____________________
3
Date of last sample:
__________________
mg/L
4
Lab result:
5
6
Fluoride Additive Data:
7
Fluorosilicic
Sodium Fluorosilicate
8
Manufacturer: ___________________________________
9
Is product ANSI-NSF Standard 60 approved?
Yes
%
10
P
_________________
ercent strength of acid used:
2
S
_______________ g/cm
11
pecific Gravity (SG) of acid:
12
13
Testing and Monitoring:
14
*Instrument used in Field Testing (make/model):
15
__________________________________________________
16
Method used (check one):
SPADNS
Electrode
17
Weekly Instrument Calibration:
18
19
Date
Standard mg/L
Result mg/L
20
21
22
23
24
25
26
Date Split Sample Taken: _______________________
27
28
Process Interruptions (date/time):
29
30
1st Start:
31
End:
Total
2nd Start:
Min
End:
Max
3rd Start:
Avg
End:
Count Total
Explain cause and corrective actions taken for
Count within range
interruption(s) on back of page.
Percent within range
Please send your report to us by the 10th day of the following month.
Certified Operator Signature: ______________________________________________________
Date: ___________________________
Washington Certification No.: ________________________________________________
For people with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-525-0127
(TDD/TTY call 711).
Fluoridation Monthly Operations Report - Supplemental Form
Explain cause and corrective actions taken for each interruption/overfeed.
(Use this page to the report if these occurred during the month. Add additional pages, if needed.)
Cause and Response
Date(s)
Certified Operator signature:
Date:
_____________________________________________
____________________________
Please send completed form to: Office of Drinking Water, Water Quality Section
PO BOX 47822, Olympia, WA 98504-7822  Fluoride@doh.wa.gov  Fax: 360-236-2252
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