"Monthly Operations Report for Groundwater Systems and Systems Purchasing Water" - Vermont

Monthly Operations Report for Groundwater Systems and Systems Purchasing Water is a legal document that was released by the Vermont Department of Environmental Conservation - a government authority operating within Vermont.

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  • Released on May 27, 2016;
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FORM
Drinking Water and Groundwater Protection Division
Monthly Operations Report
for Groundwater Systems and Systems Purchasing Water
For the Month of
20_
WSID#
Name of Water System
Town/City
Operator Name
Phone:
Please provide the following information:
1. Is a master meter which measures total water production of the system installed and functioning?
YES
NO
2. Meter reading on last day of reporting month: ______________ Gallons
3. Meter reading on last day of previous month:
_____________
Gallons
4. Difference in readings:
Gallons
5. Have the results of all water quality compliance analyses performed during this month been submitted to
the Water Supply Division? YES
NO
(If NO, please submit a copy of all results with this monthly report.)
6. If you disinfect, fluoridate or otherwise treat your water on any day of the month, or if your operating
permit requires that you report daily values of flow (or other) you must also complete the reverse side of
this form.
7. For systems with population greater than 3,300, continuous monitoring for free chlorine residuals is
required:
Did continuous monitoring equipment fail at any time this month? YES
NO
If yes, were grab samples collected every 4 hours until continuous monitoring equipment was
returned to service? YES
NO
___ Date &
_____Time equipment failed
___ Date &
_____Time it was returned to service
I certify, as the owner or authorized representative* of this water system, that I have completed this form, or
reviewed it if completed by another, and that I have taken the necessary steps to ensure that the information shown is
correct. In making this certification, I understand that civil and or criminal penalties may be imposed for submitting false
information.
Signature
Date
Please Type or Print Name
*Owner means the person who owns or has an ownership interest in a Public or Non-public water system. An Owner
may designate an Authorized Representative that has the authority to act on the owner’s behalf in all matters
regarding the Public or Non-public water system, and is designated to be the contact person in place of the owner for all
communications from the Secretary regarding the water system. A form designating an authorized representative and
signed by the Owner must be on file with the Drinking Water and Groundwater Protection Division.
Rev 5/27/2016
Page 1 of 2
FORM
Drinking Water and Groundwater Protection Division
Monthly Operations Report
for Groundwater Systems and Systems Purchasing Water
For the Month of
20_
WSID#
Name of Water System
Town/City
Operator Name
Phone:
Please provide the following information:
1. Is a master meter which measures total water production of the system installed and functioning?
YES
NO
2. Meter reading on last day of reporting month: ______________ Gallons
3. Meter reading on last day of previous month:
_____________
Gallons
4. Difference in readings:
Gallons
5. Have the results of all water quality compliance analyses performed during this month been submitted to
the Water Supply Division? YES
NO
(If NO, please submit a copy of all results with this monthly report.)
6. If you disinfect, fluoridate or otherwise treat your water on any day of the month, or if your operating
permit requires that you report daily values of flow (or other) you must also complete the reverse side of
this form.
7. For systems with population greater than 3,300, continuous monitoring for free chlorine residuals is
required:
Did continuous monitoring equipment fail at any time this month? YES
NO
If yes, were grab samples collected every 4 hours until continuous monitoring equipment was
returned to service? YES
NO
___ Date &
_____Time equipment failed
___ Date &
_____Time it was returned to service
I certify, as the owner or authorized representative* of this water system, that I have completed this form, or
reviewed it if completed by another, and that I have taken the necessary steps to ensure that the information shown is
correct. In making this certification, I understand that civil and or criminal penalties may be imposed for submitting false
information.
Signature
Date
Please Type or Print Name
*Owner means the person who owns or has an ownership interest in a Public or Non-public water system. An Owner
may designate an Authorized Representative that has the authority to act on the owner’s behalf in all matters
regarding the Public or Non-public water system, and is designated to be the contact person in place of the owner for all
communications from the Secretary regarding the water system. A form designating an authorized representative and
signed by the Owner must be on file with the Drinking Water and Groundwater Protection Division.
Rev 5/27/2016
Page 1 of 2
Groundwater Systems and Systems Purchasing Water
For the Month of
201
WSID#
Name of Water System
Minimum free chlorine residual required for 4 Log viral inactivation (mg/l):
pH
Day of
Water
Disinfection/Chlorination
Fluoride
(0nly if providing
Month
Production
(Free CL, in mg/l)
(mg/l)
corrosion control)
Distribution System
Metered Values
Entry Point
Finished
(When taking
Entry Point
(Gallons/Day)
Daily Low
1
avg. daily
coliform sample)
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
Totals
NA
NA
NA
NA
Note:
1
Daily low for systems with continuous monitoring. Others – during the hour of peak flow.
*Please submit this form within 10 days after the end of the month to the following address:
Drinking Water and Groundwater Protection Division
nd
1 National Life Drive, Main, 2
Floor
Montpelier, VT 05620-3521
Phone 802-828-1535
Fax 1-802-828-1541
This form is available electronically at
http://www.vermontdrinkingwater.org
Rev 5/27/2016
Page 2 of 2
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