NEW YORK STATE DEPARTMENT OF HEALTH
New York State Department of Health WATER SYSTEM OPERATION REPORT
|Public Water System Name |Reporting Month/Year |Date Report Submitted | Source Water Type (s) |
| | | | |
| |__ __/ 2 0 __ __ |__ __/__ __/ 2 0 __ __ | |
| |M M Y Y Y Y |M M D D Y Y Y Y | |
| | | | Surface Ground GWUDI |
| | | | Purchase with subsequent chlorination |
| | | | Purchase w/out subsequent chlorination |
|Public Water System ID |County |Town, Village or City |
|NY ___ ___ ___ ___ ___ ___ ___ | | |
Bureau of Water Supply Protection Microbiological Sample Results
|DATE |Source(s) |Treated water volume |Chlorination |Other Treatments / Readings |
| |in use |(1,000 gallons/day) | | |
| | | |Gaseous |Liquid |Free | |
| | | | | |chlorine | |
| | | | | |residual at| |
| | | | | |entry point| |
| | | | | |(mg/l) | |
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Sample Collector(s): ________________________________________________________________________________________________________________________
Name of NYSDOH Certified Laboratory: _______________________________________________________________________________________________________
Did any MCL violation occur? If so, please describe: _____________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
Did an emergency or low pressure problem occur? Did source water bypass an existing treatment process in the system? If so, please explain: ______________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
Comments:________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
DOH-360 (02/05) Page 2 of 2
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