Free 53283.pdf - Indiana

MONTHLY CHLORITE MONITORING
State Form 53283 (6-07)

Indiana Department of Environmental Management (IDEM) Office of Water Quality - Drinking Water Branch - Compliance Section

INSTRUCTIONS:

1- For each day of the month, record a daily chlorite sample measurement taken at the point of entry (POE). 2- Indicate "yes" or "no" if the daily chlorite POE measurement exceeds 1.0 mg/L. 3- On each day following a daily chlorite POE measurement that exceeds 1.0 mg/L, record sample results for three distribution samples taken (one at the first customer, one at a location representing average residence time, and one at a location representing maximum residence time). 4- Record sample results for three routine monthly distribution system chlorite samples (one at the first customer, one at a location representing average residence time, and one at a location representing maximum residence time). Distribution system monitoring of chlorite as a result of a daily POE MCL exceedance may be used to meet the monitoring requirements for routine monthly distribution system monitoring.

MONTHLY CHLORITE MONITORING (page 2)
State Form 53283 (6-07)

PWSID # System Name: Treatment Plant Name/Number: Submitted by: Month Year

Please submit completed forms to:
IDEM OWQ Drinking Water ­ Mail Code 66-34 100 N. Senate Ave. Indianapolis, IN 46204-2251

Has reduced monitoring been granted for monthly chlorite monitoring? Three (3) Routine Monthly Distribution System Chlorite Samples

Point-Of-Entry (POE) Chlorite Samples Is the level > 1.0 mg/L?

Day 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

Level (mg/L)

Three (3) Distribution System Chlorite Samples Level at Level at the location Level at the st 1 of maximum location of average customer residence time residence time (mg/L) (mg/L) (mg/L)

Level at 1st customer (mg/L)

Level at location of average residence time (mg/L)

Level at location of maximum residence time (mg/L)

Dates which chlorite concentration > 1.0 mg/L: