MONTHLY OPERATION REPORT FOR PWSs FLUORIDATING WATER
See page 3 for instructions.
I. General Information for the Month/Year of:
A. Public Water System (PWS) Information
PWS Name:
PWS Type:
Community
Non-Transient Non-Community
Number of Service Connections at End of Month:
PWS Owner:
Contact Person:
Contact Person's Mailing Address:
Contact Person's Telephone Number:
Contact Person's E-Mail Address:
B. Water Treatment Plant Information
Plant Name:
Plant Address:
PWS Identification Number:
Transient Non-Community
Consecutive
Total Population Served at End of Month:
Contact Person's Title:
City:
Contact Person's Fax Number:
City:
State:
Plant Telephone Number:
State:
Zip Code:
Zip Code:
II. Certification by Lead/Chief Operator
I, the undersigned water treatment plant operator licensed in Florida, am the lead/chief operator of the water treatment plant identified in Part I of this report. I certify that the
information provided in this report is true and accurate to the best of my knowledge and belief.
Signature and Date
Printed or Typed Name
License Number
III. Check Sample Results for the Month/Year of:*
Sample Name/Number
Distribution System Sample 1
Distribution System Sample 2
Sample Location
Fluoride Concentration in Sample per
Analysis by Authorized Representative of
PWS, mg/L
Fluoride Concentration in Sample per
Analysis by DOH Laboratory or Laboratory
Certified by DOH, mg/L
* Complete Part III of this report only for PWSs not using a certified laboratory to perform all daily measurements of fluoride concentration in the finished water from each of the
PWS's treatment plants.
DEP Form 62-555.900(5)
Effective August 28, 2003
Page 1
MONTHLY OPERATION REPORT FOR PWSs FLUORIDATING WATER
PWS Identification Number:
Plant Name:
IV. Daily Fluoridation Data for the Month/Year of:
Type of Fluoride Chemical Used:
Sodium Fluoride
Sodium Fluosilicate (Silicofluoride)
Fluosilicic (Hydrofluosilicic) Acid
Commercial Purity of Fluoride Compound Used (per the chemical supplier), % =
Day of
Quantity of Fluoride Chemical
the
Net Quantity of Finished Water
Fed, pounds (or gallons for
Month
Hours Plant in Operation
Produced, gallons
Fluosilicic Acid)
Fluoride Dose, mg/L
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
0
0
Total
Average
DEP Form 62-555.900(5)
Effective August 28, 2003
Page 2
Fluoride Concentration in
Finished Water at Entry to
Distribution System, mg/L
MONTHLY OPERATION REPORT FOR PWSs FLUORIDATING WATER
INSTRUCTIONS: This report shall be completed and submitted by all public water systems fluoridating water. WITHIN TEN DAYS AFTER THE END OF EACH MONTH,
complete this report and submit it to the Department of Health's (DOH's) Bureau of Dental Health at 4052 Bald Cypress Way, Bin A14, Tallahassee, Florida 32399-1724. All
information provided in this report shall be typed or printed in ink. NOTE THAT A SEPARATE MONTHLY OPERATION REPORT IS REQUIRED FOR EACH
TREATMENT PLANT FLUORIDATING WATER.
The following specific instructions are for the table in Part III of this report, which shall be completed only for public water systems (PWSs) not using a certified laboratory to
perform all daily measurements of fluoride concentration in the finished water from each of the PWS's treatment plants.
SAMPLE NAME/NUMBER. For each PWS not using a certified laboratory to perform all daily measurements of fluoride concentration in the finished water from each of the
PWS's treatment plants, collect two check samples per month from the PWS's distribution system. Each check sample shall be "split" into two samples, one which shall be
analyzed by an authorized representative of the PWS and one which shall be analyzed by a laboratory of the DOH or a laboratory certified by the DOH to perform fluoride
analyses of drinking water.
SAMPLE LOCATION. For each check sample, describe the location in the PWS distribution system where the sample was collected.
FLUORIDE CONCENTRATION IN SAMPLE PER ANALYSIS BY AUTHORIZED REPRESENTATIVE OF PWS and FLUORIDE CONCENTRATION IN SAMPLE PER
ANALYSIS BY DOH LABORATORY OR LABORATORY CERTIFIED BY DOH. For each check sample, enter the fluoride concentration in the sample per analysis by an
authorized representative of the PWS and enter the fluoride concentration in the sample per analysis by a laboratory of the DOH or a laboratory certified by the DOH. Submit a
copy of the laboratory's analytical results along with this report.
The following specific instructions are for the table in Part IV of this report.
HOURS PLANT IN OPERATION. For each day the plant is in operation, enter the number of hours that the plant is in operation.
NET QUANTITY OF FINISHED WATER PRODUCED. Enter the net quantity of finished water, excluding any filter backwash water, produced by the plant for each day the
plant is in operation; compute and enter the total net quantity of finished water produced for the month; and compute and enter the average daily net quantity of finished water
produced for the month. If the plant is staffed during every hour it is in operation or if the plant has flow recording equipment, enter the net quantity of finished water produced
between 12:00 midnight and 12:00 midnight for each day the plant is in operation. If the plant is not staffed during some hours it is in operation and if the plant does not have
flow recording equipment, read the totalizing flow meter(s) (or the elapsed time clock[s]) at approximately the same time each day and enter the net quantity of finished water
produced during the one day since the meter(s) (or the elapsed time clock[s]) was(were) last read.
QUANTITY OF FLUORIDE COMPOUND FED and FLUORIDE DOSE. For each day the plant is in operation, enter the quantity of fluoride chemical fed and the fluoride
dose. Also, for the month, compute and enter the total quantity of fluoride compound fed and compute and enter the average daily quantity of fluoride chemical fed.
FLUORIDE CONCENTRATION IN FINISHED WATER AT ENTRY TO DISTRIBUTION SYSTEM. For each day the plant is in operation, enter the fluoride concentration
in the finished water at the entry to the distribution system. Also, for the month, compute and enter the average of the daily measurements for fluoride concentration at the entry
to the distribution system. (Note that the daily measurements of fluoride concentration in the finished water may be performed by any authorized representative of the PWS.
However, if the daily measurements of fluoride concentration in the finished water are not performed by a certified laboratory, check samples must be collected, analyzed, and
reported in accordance with Part III of this report.)
DEP Form 62-555.900(5)
Effective August 28, 2003
Page 3