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July 2008
IMINNESOTA DEPARTMENT OF HEALTH Section of Water Supply See instructions on reverse side to complete form.. and Well Management PWS ID * Month of pp Fluoridation Monthly Report g c/ boo,9a G y-- Name of Facility Street o . • City -- County -- Zip Code �o l 0a4 ® -� "" S-S-o g�-_ 5, re Title Phone # gite /Yr-e - .VcnJ e5/- y39" tiy3q Fluoride Chemical Used Cam✓ Raw Water Fluoride Concentration Water Source•A t9 �N9Q 0..2.4 mg/l -at #- 10L1074 Amount of Solution • Fluoride Analysis Meter or Compound Tested Fluoride Sampling Point Reading Pumpage Used Per Concentration on Distribution Date (1000 gal.) (1000 gal.) •Day (gal. or lbs.) (mg/I) System 1 2 3 4 5 . 1 4FR74j 903 1ff0 • /./ 7 atitaAvyk. ii4,14 2 4,204 0$_5 /0 74, ,5.0 . /119 IJ ale l -w 4 er;(9 , 2_746 //3 i . 41) ii, 6-' • 4-7 -OW"714,4„/ .0.-7-41 4.i / T 6 Z I o D '11 1 q (o `- 4/ i.�3 "/, v. D.S 7 . A / I 1 7a I f I A 5a o • /.0-1 8 a two-4002 _ 10 70 Li.s c347 f{ -� 9 113433 . / I.7 _ s- S /- 33 er �<<- 10 a 144,70 833 To i..21 • ► C t 11 . Q i sa 4,/ 1 1.1 Y S A a6 02A� 12 2l U 1 .Sy //54- S 0 1 ,Z L'Lc.! ! • e� ' /A- 13 21 1 d A 5 630 • 3 6 U4/it f &kJ 4.4.. 14 a' : O0Li, - 9S" to . 10 r wilf77 is 219004 /000 4. 0 /. 31 (c 9 I&� 16 c2/760ci 17 18 . • 19 20 • 21 22 23 24 25 26 27 28 29 . 30 31 41100`1 Copy to be sent back each month to: Minnesota Department of Health, Public Water Supply Untt, P.O. Box 64975, St. Paul, Minnesota 55164-0975 HE-00818-02 'Cif a © , 000 F1-; IC 140-0013 MINNESOTA DEPARTMENT OF HEALTH Section of Water Supply See instructions on reverse side to complete form. • and Well Management pyyg ID Month of Fluoridation Monthly Report • C O Name of Facility Street City County Zp Code t�re f-��l� title Phone # gee a .(L&& 71 firA F� ' 'rl , 6s/- cf 39-yy3 _ Fluoride Chemical Used , G ��Gf Raw Water Fluoride Concentration Water Source �ei ��A-e-4-fi " � ,7o O s 114 1 mg/I .lie-e/ # 777 176 Amount of Solution • Fluoride Analysis Meter or Compound Tested Fluoride Sampling Point Reading Pumpage Used Per Concentration on Distribution Date (1000 gal.) (1000 gal.) Day (gal. or lbs.) _ (mg/I) System 1 2 3 4 5 . 1 • 2 • 3 4 • . 1 5 6 777 1) .5""19 A i ?J • 7 • 177 4-795 / P f / . o • 8 9 10 11 - - 12 . . 13 _ 14 • . 15 ? ?g > -2 32 ,/.S /. 3 / - /5---,77/ // 16 777_ 307- / .D0 / 6 isa / ( £°A' Pot.)ok. 17 . -7 8 6 z 6 6 / 0 .34 bra- t k6 LE-C. AL co. i8 , 7 r/ l.5~ /C1 `��4I �� 3, cc,i`5�o 19 78- .7f 7 9'7f 7. <'� if/ /I u v�vc> ffel/s 20 7ii'', ps''s 7?4- 3 , / . ,D8- S o 21 , 73 7,73 73 (1 ite 5-- 102 '7 7 e 22 78 i787 TV f fr] / F// ■ r e 23 78577`7 410 Li 1.30 •' 57 m- 24 78e, ei 4 g t I S`1 _ S'tS /./.5- it ' 7-2 ,e 25 -7$$ !O5 . 1177 5'..5' J-!S 6, CcC f s 7 fei'1 l y � �5 �� _Z °Z " g q6, z _ 28 o 6 fS I , O .5 Sw �te 79 8 79 '' 29 -7471 7 89 913 -s S 1 f i 5 5.,itin� 30 , 14/014/4/47 /4.0_' _ 5.5 I. 3'f _ .5•A. 1.0-t - 31 ' `791/087 /091 55 , /-.1.1 V S 2211 aw- Copy to be sent back eacti month to: Minnesota Department of Health, Public Water Supply Unit, P.O. Box 64975, St. Paul, Minnesota 55164-0975 HE-00818-02 /6/377/6oa fl-i: IC 140-0013