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 1 2 3 4 5 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) Precipitation - Inches 0 Air Temperature Man-Hours at Plant (Plants less than 1 MGD only) Day of Week Day Of Month 29 30 31 Total= Certificate Number Expiration Date 9999 6/30/2002 V RAW SEWAGE Chris A. Operator Susp. Solids - lbs State Form 53340 (R / 11-08) 555/555-1234 Ammonia - mg/l Facility's e-mail address (if available): 1/1/200 Telephone Number Phosphorus - mg/l Monthly Report of Operation Trickling Filter or RBC 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 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 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. 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 53340 (R / 11-08) For Month Of: January Phosphorus - mg/l Dissolved Oxygen mg/l CBOD5 - mg/l Dissolved Oxygen After 1st Stage FINAL EFFLUENT pH SECONDARY EFFLUENT Load Cell Weight - 1000 lbs. Biological Growth (L)ight, (N)ormal, (H)eavy Total Flow to Filter - mgd Dissolved Oxygen mg/l Susp. Solids - mg/l CBOD5 - mg/l Day Of Month RBC Trickling Filter E. Coli - colony/100 ml PRIMARY EFFLUENT 2009 Residual Chlorine Final IN0000000 Date (month, day, year ) Residual Chlorine Contact Tank Exampleville Year Dissolved Oxygen mg/l 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 Trickling Filter or RBC 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 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 53340 (R / 11-08) For Month Of: Exampleville IN0000000 January 2009 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 Date (month, day, year ) FINAL EFFLUENT Total Suspended Solids BOD Effluent Flow Weekly Average Effluent Flow Rate (MGD) Day Of Month Flow Year Ammonia - lbs/day Weekly Average Permit Number Ammonia - lbs Name of Facility Date (month, day, year ) Signature of principal executive officer or authorized agent Monthly Report of Operation Trickling Filter or RBC Wastewater Treatment Plant 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 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 Page 3 of 4 0 0 0 0 0 0 0 0 Total Monthly Flow: Phosphorus (million gallons) 0 Percent Capacity (actual flow/design) NA American LegalNet, Inc. www.FormsWorkflow.com Signature of Certified Operator State Form 53340 (R / 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 Secondary 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 Trickling Filter or RBC 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 4 American LegalNet, Inc. www.FormsWorkflow.com