Monthly Report Of Operation Package Type Wastewater Treatment Plants Less Than 0.05 MGD {53344}

MONTHLY REPORT OF OPERATION PACKAGE TYPE WASTEWATER TREATMENT PLANTS LESS THAN 0.05 MGD State Form 53344 (R / 3-14) Name of Facility Permit Number Phone Number: Certified Operator: Name Class Certificate Number Expiration Date E-mail Address: /1/ General Information Day of the Month Day of the Week Precip. - Inches Bypasses/ Overflows Influent Flow Rate If Metered (MGD) Month: Year Treatment Plant design flow: mgd Raw Wastewater Phosphorus (mg/l) 30 Minute Settling Phosphorus (lbs) Ammonia (mg/l) Ammonia (lbs) Aeration Tank Effluent Flow Rate (MGD) Final Effluent Collection System ("x" if occurred) Sludge Vol. Index (SVI) - ml/gm At Plant Site ("x" if occurred) CBOD (mg/l) CBOD (mg/l) Temperature CBOD (lbs) CBOD (lbs) Man Hours TSS (mg/l) TSS (mg/l) WAS Gal. TSS (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 Total 0 0 0 0 I certify under penalty of law that this document and all attachments were Prepared by or under the direction of (Certified Operator): Date (month, day, year ) Sludge Hauled Off Site (Gal): 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 belief, true, accurate, and Signature of principal executive officer or authorized agent (or complete. I am aware that there are significant penalties for submitting false attested by NetDMR subscriber agreement) information, including the possibility of fine and imprisonment for knowing violations. Date (month, day, year ) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com TSS (lbs) MLSS D.O. pH pH Name of Facility: Month/Year: MONTHLY REMOVAL SUMMARY BOD5 S.S. Ammonia Percent Removal Phosphorus Total Monthly Flow Percent Capacity mg (average flow / design) Final Effluent Phosphorus (mg/l) Residual Chlorine (mg/l) - Contact Residual Chlorine (mg/l) - Final Day of the Month Phosphorus (lbs) Ammonia (mg/l) Ammonia (lbs) E. Coli colony/100 ml Enter Comments Below: 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 Send by 28th of the Month to: Indiana Department of Environmental Management Office of Water Quality, Mail Code 65-42 100 North Senate Avenue Indianapolis, Indiana 46204-2251 American LegalNet, Inc. www.FormsWorkFlow.com D.O. (mg/l) Page 2 of 2