Name of Facility Exampleville IN0000000 Month Plant Design Flow January 2009 0.002 mgd wwtp@city.org Certified Operator: Name Class Mon Tue Wed 1 2 3 4 5 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 9999 Expiration Date 6/30/2008 Ammonia - mg/l 1/1/200Facility's e-mail address (if available): Telephone Number Susp. Solids - lbs State Form 53339 (R / 11-08) Year Phosphorus - mg/l Monthly Report of Operation Sequencing Batch Reactor 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 Signature of principal executive officer or authorized responsible for gathering the information, the information submitted is, to the best of my agent 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. Page 1 of 4 0 0 0 0 Date (month, day, year ) Date (month, day, year ) American LegalNet, Inc. www.FormsWorkflow.com Signature of Certified Operator State Form 53339 (R / 11-08) For Month Of: January Phosphorus - mg/l 0 Dissolved Oxygen mg/l 0 pH - daily high (if multiple samples) 0 pH - daily low (or single sample) 0 E. Coli - colony/100 ml 0 FINAL EFFLUENT Residual Chlorine Final Settleable Solids % in 30 minutes REACTOR # 3 Dissolved Oxygen mg/l 0 Sludge Vol. Index - ml/gm 0 Susp. Solids - mg/l Settleable Solids % in 30 minutes REACTOR # 2 Dissolved Oxygen mg/l 0 Sludge Vol. Index - ml/gm 0 Susp. Solids - mg/l Settleable Solids % in 30 minutes Day Of Month Temperature in Reactors REACTOR # 1 2009 Residual Chlorine Contact Tank 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 Sequencing Batch 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 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 53339 (R / 11-08) For Month Of: January FINAL EFFLUENT Total Suspended Solids Other Ammonia - lbs/day Weekly Average Ammonia - lbs Ammonia - mg/l Weekly Average Ammonia Ammonia - mg/l CBOD5 - lbs/day Weekly Average CBOD5 - lbs CBOD5 - mg/l CBOD5 - mg/l Weekly Average BOD Effluent Flow Weekly Average Effluent Flow Rate (MGD) Day of Week Day Of Month Flow 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 Sequencing Batch Reactor Wastewater Treatment Plant 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 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 Total Monthly Flow: Phosphorus NA (million gallons) 0 Percent Capacity (actual flow/design) Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com Monthly Report of Operation Sequencing Batch Reactor Wastewater Treatment Plant Signature of Certified Operator Signature of principal executive officer or authorized agent State Form 53339 (R / 11-08) Name of Facility Permit Number For Month Of: Exampleville IN0000000 January SLUDGE TO DIGESTER 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 Day Of Month Year Date (month, day, year ) 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