Doh-360cuv - Water System Operation Report For Systems That Treat With Chlorine And/or Ultraviolet Radiation

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Water System Operation Report
NEW YORK STATE DEPARTMENT OF HEALTH
For Systems that Treat with Chlorine and/or Ultraviolet Radiation
Bureau of Water Supply Protection
Public Water System Name:
Public Water System ID: NY
County:
Town, Village or City:
Source Water Type(s):
Surface
Ground
GWUDI
Reporting Month/Year:
Date Report Submitted:
Purchase with subsequent chlorination
MM/YYYY
MM/YYYY
Purchase w/out subsequent chlorination
4 log treatment required
CHLORINATION
ULTRAVIOLET RADIATION/OTHER TREATMENTS
Gaseous
Liquid
Free
Quartz
chlorine
Treated water
Cylinder
Chlorine
Hypochlorite
UV Unit
Intensity
sleeve
Checked
residual at
Source(s)
volume
weight
used/Day
added to crock
active
meter
cleaned
by
entry point
Date
in use
>70%
(GALLONS/DAY)
(LBS.)
(LBS.)
(GALLONS OR QUARTS)
(YES/NO)
(YES/NO)
(INITIALS)
(mg/l)
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
TOTAL
AVG
Chlorine Mix Ratio =
quarts/gallons of
% chlorine added to
gallons of water in crock.
Date UV quartz sleeve last cleaned:
Date UV lamp replaced:
MM//DD/YY
MM//DD/YY
Alarm activation:
No
Yes
If “Yes,” date of activation:
Required Treatment Residual Level:
mg/l
MM//DD/YY
NYSDOH Operator
Reported by:
Title:
Certification Number:
Signature:
Date:
Operator Grade Level:
MM//DD/YY
DOH-360CUV (01/10) Page 1 of 2

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