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: _____________________________________________________________________________________________

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Did an emergency or low pressure problem occur? Did source water bypass an existing treatment process in the system? If so, please explain: ______________________

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Comments:________________________________________________________________________________________________________________________________

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DOH-360 (02/05) Page 2 of 2

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