DOH Form 331-496-F "Fluoridation Monthly Operations Report Form for Sodium Fluoride Saturators" - Washington

What Is DOH Form 331-496-F?

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 331-496-F 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 331-496-F "Fluoridation Monthly Operations Report Form for Sodium Fluoride Saturators" - Washington

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Fluoridation Monthly Operations Report Form
DOH Form 331-496-F
Dec-14
for Sodium Fluoride Saturators
System Name: ________________________________________
System ID No: _____________________________________
FIP No: ______________________________________________
Month/Year: ______________________________________
Contact Person: _______________________________________
Telephone No: ________________________________
The Department of Health supports water
Water Production
Fluoride Additive
Monitoring
Meter Reading Vol Treated Added to
Meter Reading
Volume
Calculated
Field Test
fluoridation as a sound population-based public
Date
Saturator
Used
Dosage
Result*
health measure, and supports communities in
(1000 gals)
(1000 gals)
(lbs)
(gals)
(gals)
(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
Manufacturer: ____________________________
Yes
8
Is product ANSI-NSF Standard 60 approved?
9
10
Testing and Monitoring:
11
*Instrument used in Field Testing (make/model):
12
____________________________________________
13
Method used (check one):
SPADNS
Electrode
14
Weekly Instrument Calibration:
15
16
Date
Standard mg/L
Result mg/L
17
18
19
20
21
22
23
Date Split Sample Taken: _______________________
24
25
Process Interruptions (date/time):
26
27
1st Start:
28
End:
29
2nd Start:
30
End:
31
3rd Start:
Total
End:
Min
4th Start:
Max
End:
Avg
Explain cause and corrective actions taken for
Count Total
interruption(s) on back of page.
Count within range
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 331-496-F
Dec-14
for Sodium Fluoride Saturators
System Name: ________________________________________
System ID No: _____________________________________
FIP No: ______________________________________________
Month/Year: ______________________________________
Contact Person: _______________________________________
Telephone No: ________________________________
The Department of Health supports water
Water Production
Fluoride Additive
Monitoring
Meter Reading Vol Treated Added to
Meter Reading
Volume
Calculated
Field Test
fluoridation as a sound population-based public
Date
Saturator
Used
Dosage
Result*
health measure, and supports communities in
(1000 gals)
(1000 gals)
(lbs)
(gals)
(gals)
(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
Manufacturer: ____________________________
Yes
8
Is product ANSI-NSF Standard 60 approved?
9
10
Testing and Monitoring:
11
*Instrument used in Field Testing (make/model):
12
____________________________________________
13
Method used (check one):
SPADNS
Electrode
14
Weekly Instrument Calibration:
15
16
Date
Standard mg/L
Result mg/L
17
18
19
20
21
22
23
Date Split Sample Taken: _______________________
24
25
Process Interruptions (date/time):
26
27
1st Start:
28
End:
29
2nd Start:
30
End:
31
3rd Start:
Total
End:
Min
4th Start:
Max
End:
Avg
Explain cause and corrective actions taken for
Count Total
interruption(s) on back of page.
Count within range
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 report if occurring during the month. Add additional pages, as needed.)
Cause and Response
Date(s)
Certified Operator signature: ____________________________________________
Date: ______________
Please send the form to: Office of Drinking Water, Water Quality Section
PO BOX 47822, Olympia, WA 98504-7822  Fluoride@doh.wa.gov  Fax: 360-236-2252
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)
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