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Get TX TCEQ-20067 2015

PWS / / MR / /DLQOR DISINFECTANT LEVEL QUARTERLY OPERATING REPORT DLQOR FOR GROUNDWATER OR PURCHASED-WATER PUBLIC WATER SYSTEMS-ANY SIZE Select Quarter Select Year PWS Name PWS ID Type of Disinfectant Used in Distribution System If you used chloramines and free chlorine at any time during this quarter select both. Always print and sign form and keep a copy with your records for TCEQ review. Step 1 Print Copy For your own records TCEQ-20067 Revised 02/26/2015 Step 2 Print to Mail Sign and Mail to TCEQ / PDW MC-155 Attn DLQOR PO Box 13087 Austin TX 78711-3087 Click the button below to start over or to reset to enter data for a different system. Clear Form. First Month of Quarter Monthly Summary Month Was the PWS active this month Average of all disinfectant YES NO Number of residuals Number below MIN Number with NO residual collected this month residuals for this month mg/L for this month readings Second Month of Quarter Monthly Summary Number below MIN Number with NO residual Third Month of Quarter Monthly Summary Quarterly Summary and Certification Lowest residual for this quarter Highest residual I certify that I am familiar with the information contained in this report and that to the best of my knowledge the information is true complete and accurate. Name Enter Name Today s Date Signature Title Phone Number Email address License Complete this form for the previous quarter at the beginning of April July October and January and submit in time for it to be received by the TCEQ by the 10th of the month. First Month of Quarter Monthly Summary Month Was the PWS active this month Average of all disinfectant YES NO Number of residuals Number below MIN Number with NO residual collected this month residuals for this month mg/L for this month readings Second Month of Quarter Monthly Summary Number below MIN Number with NO residual Third Month of Quarter Monthly Summary Quarterly Summary and Certification Lowest residual for this quarter Highest residual I certify that I am familiar with the information contained in this report and that to the best of my knowledge the information is true complete and accurate. Name Enter Name Today s Date Signature Title Phone Number Email address License Complete this form for the previous quarter at the beginning of April July October and January and submit in time for it to be received by the TCEQ by the 10th of the month. .

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