Name of Facility Exampleville IN0000000 Month Year Plant Design Flow January 2009 0.001 mgd wwtp@city.org Certified Operator: Name Class Mon Tue Wed 1 2 3 4 5 Expiration Date 9999 Susp. Solids - lbs Susp. Solids - mg/l CBOD5 - lbs CBOD5 - mg/l pH Influent Flow Rate (if metered) MGD Lbs/Day or Gal./Day Lbs/Day or Gal./Day 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 555/555-5555 6/30/2000 Ammonia - mg/l Facility's e-mail address (if available): 1/1/200 State Form 10829 (R3 / 11-08) Telephone Number Phosphorus - mg/l Monthly Report of Operation Activated Sludge Type Wastewater Treatment Plant Permit Number Thu 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Fill in December's effluent data on page 3 as necessary for correct weekly average calculations. Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue 21 22 23 24 25 Wed 26 27 28 29 30 31 Mon Thu Fri Sat Sun Tue Wed Thu Fri Sat Average Maximum Minimum No. of Data 0 0 0 0 0 0 0 0 0 0 0 Signature of Certified Operator I certify under penalty of law that this document and all attachments were 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 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. 0 0 0 0 Date (month, day, year) Date (month, day, year) Page 1 of 5 American LegalNet, Inc. www.FormsWorkflow.com Signature of Certified Operator State Form 10829 (R3 / 11-08) For Month Of: January FINAL EFFLUENT SECONDARY Phosphorus - mg/l Dissolved Oxygen mg/l pH - daily low (or single sample) pH - daily high (if multiple samples) EFFLUENT CBOD5 - mg/l Volume - MG Temperature - F RETURN SLUDGE Dissolved Oxygen mg/l Sludge Vol. Index - ml/gm Susp. Solids - mg/l Settleable Solids % in 30 minutes Susp. Solids - mg/l CBOD5 - mg/l Day Of Month AERATION MIXED LIQUOR Susp. Solids - mg/l PRIMARY EFFLUENT 2009 E. Coli - colony/100 ml IN0000000 Date (month, day, year) Residual Chlorine Final Exampleville Year Residual Chlorine Contact Tank 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 Activated Sludge Type 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 0 Comments for the Month (major repairs, breakdowns, process upsets and their causes, inplant treatment process bypass, etc.): Page 2 of 5 American LegalNet, Inc. www.FormsWorkflow.com Monthly Report of Operation Activated Sludge Type Wastewater Treatment Plant Signature of Certified Operator Signature of principal executive officer or authorized agent State Form 10829 (R3 / 11-08) For Month Of: IN0000000 January Other Ammonia - mg/l Ammonia - mg/l Weekly Average Ammonia Susp. Solids - lbs/day Weekly Average Susp. Solids - lbs Susp. Solids - mg/l Weekly Average Susp. Solids - mg/l CBOD5 - lbs/day Weekly Average CBOD5 - lbs CBOD5 - mg/l Weekly Average CBOD5 - mg/l 2009 FINAL EFFLUENT Total Suspended Solids BOD Effluent Flow Weekly Average Effluent Flow Rate (MGD) Day of Week Day Of Month Flow Date (month, day, year) Oil & Grease (mg/l) Exampleville Year Ammonia - lbs/day Weekly Average Permit Number Ammonia - lbs Name of Facility Date (month, day, year) 29 Mon 30 Tue 31 Wed 1 2 3 4 5 Thu 6 7 8 9 10 Tue 11 12 13 14 15 Sun 16 17 18 19 20 Fri 21 22 23 24 25 Wed 26 27 28 29 30 31 Mon Fri Sat Sun Mon Wed Thu Fri Sat Mon Tue Wed Thu Sat Sun Mon Tue Thu Fri Sat Sun Tue Wed Thu Fri Sat Avg Max Min Data 0 0 Percent Removal Primary Treatment Secondary Treatment Tertiary Treatment Overall Treatment 0 0 0 0 0 0 MONTHLY REMOVAL SUMMARY BOD5 S.S. Ammonia NA NA NA NA NA NA NA NA NA 0 0 0 0 0 0 0 0 Total Monthly Flow: Phosphorus (million gallons) 0 Percent Capacity (actual flow/design) NA Page 3 of 5 American LegalNet, Inc. www.FormsWorkflow.com Signature of Certified Operator State Form 10829 (R3 / 11-08) Name of Facility Permit Number For Month Of: Exampleville IN0000000 January Date (month, day, year) 2009 DIGESTER OPERATION Digested Sludge Withdrawn hrs. or Gal. x 1000 Volatile Solids in Digested Sludge - % Volatile Solids in Incoming Sludge - % Total Solids in Digested Sludge - % Total Solids in Incoming Sludge - % Supernatant BOD5 mg/l or NH3-N mg/l Supernatant Withdrawn hrs. or Gal. x 1000 Temperature - F pH Gas Production Cubic Ft. x 1000 Anaerobic Only Waste Act. Sludge Gal. x 1000 Primary Sludge Gal. x 1000 Day Of Month SLUDGE TO DIGESTER Year Date (month, day, year) Signature of principal executive officer or authorized agent Monthly Report of Operation Activated Sludge Type 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 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 5 American LegalNet, Inc. www.FormsWorkflow.com Signature of Certified Operator State Form 10829 (R3 / 11-08) Name of Facility Permit Number IN0000000 Exampleville For Month Of: Year January Date (month, day, year) Signature of principal executive officer or authorized agent Monthly Report of Operation Activated Sludge Type Wastewater Treatment Plant Date (month, day, year) 2009 Day Of Month Substitute for State Form 30530 29 30 31 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 Page 5 of 5 American LegalNet, Inc. www.FormsWorkflow.com