Doh-360cuv - Water System Operation Report For Systems That Treat With Chlorine And/or Ultraviolet Radiation Page 2
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1
2Microbiological Samples and Free Chlorine Residual
Sample
Population Served:
Total
E. coli
Free
Type
Coliform
Positive
Chlorine
1. ROUTINE
Positive
Residual
Number of microbiological monitoring samples required:
Date of
2. REPEAT
Sample
Sample Location
Y
N
Y
N
(mg/l)
3. TRIGGERED
Number of microbiological monitoring samples taken:
Did a M&R violation occur?
Yes
No
If “Yes,” check reason (s) below:
Actual number of samples is fewer than required
Did not collect/analyze repeat sample
Did not collect/analyze for E. coli for positive total coliform
from routine / repeat sample
Was triggered source water monitoring required?
Yes
No
Did a MCL violation occur?
Yes
No
If “Yes,” check reason(s) below (see also Part 5, Table 6 for
Additional information).
For systems collecting less than 40 samples per month: two
or more of the samples (routine and/or repeat) are positive
for total coliform (= total coliform MCL violation).
For systems collecting 40 or more samples per month: more
than 5% of the samples (routine and/or repeat) are positive
for total coliform (= total coliform MCL violation).
The original sample was E.coli positive and at least 1 repeat
sample was positive for total coliform (= E.coli MCL
violation).
Reminder: System must collect a minimum of five (5) routine
microbiological monitoring samples during the month following
a repeat sample collection unless waived (to minimum of one
sample) in writing by the local health department.
As required by 5-1.72, “Operation of a Public Water System,” a
copy of this form shall be sent to your local health department
by the 10th calendar day of the next reporting period.
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-360CUV (01/10) Page 2 of 2
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