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Monthly Report Of Operation Lagoon Type Wastewater Treatment Plant Form. This is a Indiana form and can be use in Department Of Enviromental Management Statewide.
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Tags: Monthly Report Of Operation Lagoon Type Wastewater Treatment Plant, 53343, Indiana Statewide, Department Of Enviromental Management
Certified Operator:
Class
Last Cell Water
Level (ft.)
Dilution Ratio
(Discharge /
Upstream)
Upstream Flow
(MGD)
E. Coli
colony/100 ml
Residual Chlorine
(mg/l) (Final)
Residual Chlorine
(mg/l) (Cont. Tank)
Controlled Discharge
D.O. (mg/l)
TSS (mg/l)
CBOD (mg/l)
pH
Effluent Flow Rate
(MGD)
Ammonia (mg/l)
Expiration Date
E-mail address:
Year:
Final Effluent
Phosphorus (mg/l)
TSS (mg/l)
CBOD (mg/l)
pH
Certificate Number
Upstream Gage
Reading (in.)
Month:
Raw Wastewater
Influent Flow Rate
(MGD)
Collection System
("x" if occurred)
Chemical Used
(lbs)
Chemical Used
(lbs)
1st Cell Water
Level (ft.)
Precip. - Inches
Day of the Week
Day of the Month
General Information
At Plant Site
("x" if occurred)
Bypasses/
Overflows
Permit Number
Ammonia (mg/l)
State Form 53343 (8-07)
Name of Facility
Send by 28th of the month to:
Indiana Department of Environmental
Management Office of Water Quality
100 North Senate Avenue
Mail Code 65-42
Indianapolis, IN 46204-2251
Phosphorus (mg/l)
Monthly Report of Operation
Lagoon Type Wastewater
Treatment Plant
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Avgerage
Maximum
Minimum
Totals
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 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.
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Date (month, day, year)
Signature of principal executive officer or authorized agent
Date (month, day, year)
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Monthly Report of Operation
Lagoon Type Wastewater
Treatment Plant
Name of Facility
Permit Number
For Month Of:
Year
State Form 53343 (8-07)
Enter Comments Below:
Ammonia (lbs)
Phosphorus (lbs)
TSS (lbs)
CBOD (lbs)
Effluent Loading
Ammonia (lbs)
Phosphorus (lbs)
TSS (lbs)
CBOD (lbs)
Day of the Month
Influent Loading
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Removal Rates:
Monthly Totals:
Overall BOD removal:
Influent flow (mg):
Overall TSS removal:
Effluent flow (mg):
Avg
Max
Min
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 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.
Signature of Certified Operator
Date (month, day, year )
Signature of principal executive officer or authorized agent
Date (month, day, year )
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