Name of Facility Exampleville IN0000000 Month Year Plant Design Flow January 2009 0.002 mgd wwtp@city.org Certified Operator: Name Class Mon Tue Wed Expiration Date 9999 6/30/2007 Susp. Solids - lbs Susp. Solids - mg/l CBOD5 - lbs CBOD5 - mg/l pH Influent Flow Rate (if metered) MGD Lbs or Gal Lbs or Gal CHEMICALS USED Chlorine - Lbs Bypass At Plant Site ("x" If Occurred) Collection System Overflow ("x" If Occurred) 0 Precipitation - Inches Air Temperature (optional) Man-Hours at Plant (Plants less than 1 MGD only) Day of Week Day Of Month 29 30 31 Total= Certificate Number V RAW SEWAGE Chris A. Operator 555/555-1234 Phosphorus - mg/l 1/1/200Facility's e-mail address (if available): State Form 53341 (R / 11-08) Telephone Number Ammonia - mg/l Monthly Report of Operation Vertical Loop Reactor Wastewater Treatment Plant Permit Number Fill in December's effluent data on page 3 as necessary for correct weekly average calculations. 1 Thu 2 Fri 3 Sat 4 Sun 5 Mon 6 Tue 7 Wed 8 Thu 9 Fri 10 Sat 11 Sun 12 Mon 13 Tue 14 Wed 15 Thu 16 Fri 17 Sat 18 Sun 19 Mon 20 Tue 21 Wed 22 Thu 23 Fri 24 Sat 25 Sun 26 Mon 27 Tue 28 Wed 29 Thu 30 Fri 31 Sat Average Maximum Minimum No. of Data 0 0 0 0 0 0 0 0 0 0 0 I certify under penalty of law that this document and all attachments were Signature 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 belief, true, Signature of principal executive officer or authorized agent 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. 0 0 0 0 Date (month, day, year ) Date (month, day, year ) Page 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com Signature of Certified Operator State Form 53341 (R / 11-08) For Month Of: January 0 0 0 0 0 pH - daily high (if multiple samples) 0 pH - daily low (or single sample) 0 E. Coli - colony/100 ml 0 Susp. Solids - mg/l 0 FINAL EFFLUENT Residual Chlorine Final 0 RETURN SLUDGE Residual Chlorine Contact Tank 0 Settleable Solids % in 30 minutes 0 Sludge Vol. Index - ml/gm 0 REACTOR # 3 Dissolved Oxygen mg/l 0 Susp. Solids - mg/l Sludge Vol. Index - ml/gm 0 Settleable Solids % in 30 minutes 0 Susp. Solids - mg/l Settleable Solids % in 30 minutes 0 REACTOR # 2 Dissolved Oxygen 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 Avg. Max. Min. Data Temperature in Reactors Day Of Month REACTOR # 1 2009 Volume - MG IN0000000 Date (month, day, year ) Dissolved Oxygen mg/l Exampleville Year Sludge Vol. Index - ml/gm Permit Number Susp. Solids - mg/l Name of Facility Date (month, day, year ) Signature of principal executive officer or authorized agent Monthly Report of Operation Vertical Loop Reactor Wastewater Treatment Plant 0 0 Comments for the Month (major repairs, breakdowns, process upsets and their causes, inplant treatment process bypass, etc.): Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com Signature of Certified Operator State Form 53341 (R / 11-08) For Month Of: January Ammonia - lbs Ammonia - lbs/day Weekly Average Ammonia Ammonia - mg/l Weekly Average Total Suspended Solids Ammonia - mg/l CBOD5 - lbs CBOD5 - mg/l Weekly Average CBOD5 - mg/l Phosphorus - mg/l Dissolved Oxygen mg/l Effluent Flow Weekly Average Effluent Flow Rate (MGD) Day of Week CBOD5 - lbs/day Weekly Average FINAL EFFLUENT BOD Flow Day Of Month 2009 Susp. Solids - lbs/day Weekly Average IN0000000 Date (month, day, year ) Susp. Solids - lbs Exampleville Year Susp. Solids - mg/l Weekly Average Permit Number Susp. Solids - mg/l Name of Facility Date (month, day, year ) Signature of principal executive officer or authorized agent Monthly Report of Operation Vertical Loop Reactor Wastewater Treatment Plant 29 Mon 30 Tue 31 Wed 1 Thu 2 Fri 3 Sat 4 Sun 5 Mon 6 Tue 7 Wed 8 Thu 9 Fri 10 Sat 11 Sun 12 Mon 13 Tue 14 Wed 15 Thu 16 Fri 17 Sat 18 Sun 19 Mon 20 Tue 21 Wed 22 Thu 23 Fri 24 Sat 25 Sun 26 Mon 27 Tue 28 Wed 29 Thu 30 Fri 31 Sat Avg Max Min Data 0 Percent Removal 0 0 0 0 0 0 0 MONTHLY REMOVAL SUMMARY BOD5 S.S. Ammonia NA NA NA 0 0 0 0 0 0 0 0 0 Total Monthly Flow: Phosphorus NA (million gallons) 0 Percent Capacity (actual flow/design) Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com Signature of Certified Operator State Form 53341 (R / 11-08) Name of Facility Permit Number For Month Of: Exampleville IN0000000 January 2009 Digested Sludge Withdrawn hrs. or Gal. x 1000 Volatile Solids in Digested Sludge - % Volatile Solids in Incoming Sludge - % Total Solids in Digested Sludge - % Supernatant Withdrawn hrs. or Gal. x 1000 Temperature - F Gas Production Cubic Ft. x 1000 pH Total Solids in Incoming Sludge - % DIGESTER OPERATION Anaerobic Only Waste Act. Sludge Gal. x 1000 Day Of Month Date (month, day, year ) Supernatant BOD5 mg/l or NH3-N mg/l SLUDGE TO DIGESTER Year Date (month, day, year ) Signature of principal executive officer or authorized agent Monthly Report of Operation Vertical Loop Reactor Wastewater Treatment Plant 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 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Send completed forms by the 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 Page 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com