Name of Facility 0 0 0 Sludge Hauled Off Site (Gal): 9999 Year Page 1 of 2 mgd pH Effluent Flow Rate (MGD) WAS Gal. Final Effluent Temperature D.O. MLSS 30 Minute Settling Phosphorus (lbs) Phosphorus (mg/l) Ammonia (lbs) 0 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. 0.04 Treatment Plant design flow: Aeration Tank Ammonia (mg/l) TSS (lbs) TSS (mg/l) CBOD (lbs) CBOD (mg/l) pH Influent Flow Rate If Metered (MGD) 6/30/ 2001 2008 Signature of Certified Operator Date (month, day, year ) Signature of principal executive officer or authorized agent TSS (lbs) V January Name: E-mail Address (if available): Expiration Date TSS (mg/l) Certificate Number CBOD (lbs) Class Raw Wastewater Collection System ("x" if occurred) At Plant Site ("x" if occurred) Man Hours Precip. - Inches Day of the Month Day of the Week Bypasses/ Overflows 1 Tue 2 Wed 3 Thu 4 Fri 5 Sat 6 Sun 7 Mon 8 Tue 9 Wed 10 Thu 11 Fri 12 Sat 13 Sun 14 Mon 15 Tue 16 Wed 17 Thu 18 Fri 19 Sat 20 Sun 21 Mon 22 Tue 23 Wed 24 Thu 25 Fri 26 Sat 27 Sun 28 Mon 29 Tue 30 Wed 31 Thu Average Maximum Minimum Total IN0000000 Certified Operator: Name Chris A. Operator 1/1/200Month: #: 1 State Form 53344 (8-07) Phone Number: CBOD (mg/l) Exampleville WWTP Package Type Wastewater Treatment Plants Less Than 0.05 mgd General Information Permit Number Sludge Vol. Index (SVI) - ml/gm Monthly Report of Operation Date (month, day, year ) American LegalNet, Inc. www.FormsWorkflow.com Name of Facility: Month/Year: January Exampleville WWTP Total Monthly Flow Percent Removal Percent Capacity 0 mg 2008 Phosphorus (lbs) Enter Comments Below: Phosphorus (mg/l) Ammonia (lbs) Ammonia (mg/l) E. Coli colony/100 ml Residual Chlorine (mg/l) - Final Residual Chlorine (mg/l) - Contact D.O. (mg/l) Phosphorus NA (average flow / design) Final Effluent Day of the Month MONTHLY REMOVAL SUMMARY BOD5 S.S. Ammonia NA NA NA 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 Signature of Certified Operator Date (month, day, year ) Signature of principal executive officer or authorized agent Date (month, day, year ) 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 Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com