Monthly Report Of Operation Lagoon Type Wastewater Treatment Plant {53343}

Name of Facility Permit Number MONTHLY REPORT OF OPERATION LAGOON TYPE WASTEWATER TREATMENT PLANT State Form 53343 (R2 / 3-14) Month Year Plant Design Flow Telephone Number mgd 3/1/ E-mail address: Certified Operator: Name Class Certificate Number Expiration Date Man-Hours at Plant (Plants less than 1 MGD only) Bypass At Plant Site ("x" If Occurred) Collection System Overflow ("x" If Occurred) Total= Air Temperature (optional) CHEMICALS USED RAW SEWAGE Lbs/Day or Gal./Day Precipitation - Inches Lbs/Day or Gal./Day Susp. Solids - mg/l Phosphorus - mg/l Influent Flow Rate (if metered) MGD Susp. Solids - lbs 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 Average Maximum Minimum No. of Data I certify under penalty of law that this document and all attachments were Prepared by or under the direction of (Certified Operator): prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and Signature of principal executive officer or authorized agent (or attested by NetDMR subscriber agreement) belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Date (month, day, year) Date (month, day, year) Ammonia - mg/l Chlorine - Lbs CBOD5 - mg/l Day Of Month Day of Week CBOD5 - lbs pH MONTHLY REPORT OF OPERATION LAGOON TYPE WASTEWATER TREATMENT PLANT State Form 53343 (R2 / 3-14) Name of Facility Permit Number For Month Of: Year Primary Cell Sludge Depth (ft) Measure Annually in June Primary Cell Effluent CBOD5 mg/l - Test Monthly CONTROLLED DISCHARGE Dilution Ratio (Discharge / Upstream) Upstream Flow (MGD) Last Cell Water Level (ft.) TERTIARY INFLUENT FINAL EFFLUENT E. Coli - colony/100 ml pH - daily high (if multiple samples) Dissolved Oxygen mg/l Residual Chlorine Contact Tank Residual Chlorine Final 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 Avg. Max. Min. Data Comments for the Month (major repairs, breakdowns, process upsets and their causes, inplant treatment process bypass, etc.): Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Phosphorus - mg/l pH - daily low (or single sample) Upstream Gage Reading (in.) Ammonia - mg/l Test Weekly Day Of Month MONTHLY REPORT OF OPERATION LAGOON TYPE WASTEWATER TREATMENT PLANT State Form 53343 (R2 / 3-14) Name of Facility Permit Number For Month Of: Year Flow BOD FINAL EFFLUENT Total Suspended Solids Susp. Solids - lbs/day Weekly Average Susp. Solids - mg/l Susp. Solids - mg/l Weekly Average Ammonia Other 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 Avg Max Min Data Percent Removal MONTHLY REMOVAL SUMMARY BOD5 S.S. Ammonia Phosphorus Total Monthly Flow: (million gallons) Influent Effluent Percent Capacity (influent flow/design) Overall Treatment Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Oil & Grease (mg/l) Ammonia - lbs/day Weekly Average Effluent Flow Rate (MGD) Susp. Solids - lbs CBOD5 - lbs/day Weekly Average Effluent Flow Weekly Average CBOD5 - mg/l Weekly Average Ammonia - mg/l Weekly Average Ammonia - mg/l Ammonia - lbs CBOD5 - mg/l Day Of Month Day of Week CBOD5 - lbs