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March 2008
MINNESOTA DEPARTMENT OF HEALTH Section of Water Supply See instructions on reverse side to complete form. 1 • and Well Management . pyyS 1p # Month of Fluoridation Monthly Report / a a Caps o� Name of Facility Street / 4//&�� g oce4 .0,2a _ 6,�1i/� `cQ t City . d County - Zp Code °x ©0-1a is ; GG .-,11 , 5a s a--,, Sign re Title 1 Phone # / 1t1O — 'rtsle 7,141l4 FU t &S-(- 37-W37 Fluoride Chemical Used - . r Raw Water Fluoride Concentration Water Source - V '2 4iZ 0, // mgn iv .e.q 7Vi. /,A47603 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/1) System 1 2 3 4 gu,.i4 1 /30 041 _ 9 ' 43' 1 5- // 2 2-- AgAzta 2 /30 Z 3. 0 . / 2 3 /)7e,:and 3 /310041 4139 a,oa /Mrzi Paat —,r `-/0- 4 131558 55'Y 4.5-- /..2_Z 7i . 64-4-0-e- 6 13X067 . 5O9 �,S 1.102 etrr€1- P 6 , 13P.3o‘ 41.39 01.o I. I .3' . o .aco-wn T 7 ' , /33085 579 3.o 4 / 7 lie-et:hat/S. Zc n 8 /33527 514, a•5 /..O1 ,si C -z `) 9 . 1311035 • 'j38 .1-0 , /. a y 2,1 a�Q -Matt- 10 134593 ..5'5f 3,0 /.0/6 7-4u2..a i> "P r 11 . /3119,57 36 L/ ' /, 5- /.428 "--M iuvaLj 12 /3_5-600 6 V 3 3.s , f a 27. ,-,..,fu,,r ar.xz�ro; 13 /36/80 580 3.O' /. L3 1-1. e 14 /3 to 7 (04 s-g Z..0 I. SCE /2„-/su,-e.W S. 15 J3712/ 7 4 5- 3 3 0 . _ /.. Z/ LobJE . 1s /3 7 7 6 -7 2 - Q b 3/ c }Ma- fi). 17 4 - 0 . • 0 .30 _Li AAA.i1► ' - 1s 138571 . 3 78 /,C. /. 2.4/ ,1- 7' ' 20 /.3 9589 4-114) , _ 5-: r 38 '6-- - '• ''1 21 _ /5100403 14/K "4,0 f, 35 A. , ,� 22 14 0p5 5 552. Z..0 _ I , Z f . �'f ii // It �, 23 1_404004 CO . o 9 2 -0 I , f�2_ S,A. EA S1 24 l i l L1 Qa s3$ 4i.S1. 0d- -2 f -7: 25 l y 1 r a / ' 0 /C-/ s. ( C I 26 /4495-3h 6/0 . S` /., /3 :.,44 yam e c 27 P1 Qq'i e , 28 /135 /st 566 .3.0 /. a .5- 5./}, -1' 29 )41;3155- _ 4, Z.6 , /, /5' gu2Kir e 30 1 1 /A 5S S SC,0 3. 0 /t /Z Coo�JE ie. QA-+eta, 31 ,' 11 9 505© L 5 ..2,6-- /.1 `1 _T.�,e.a..6i2.n peeve- , Copy to be sent back each month to: Minnesota D epartment of Health, Public Water Supply Unit, P.O. Box 64975, St. Paul, Minnesota 55164-0975 HE-00818-02 15r `1r f 71 o oa Fl 1_ IC 140-0013 MINNESOTA DEPARTMENT OF HEALTH Section of Water Supply See instructions on reverse side to complete form. and Well Management PWS 10 * - Month of Fluoridation Monthly Report • 1 /S 00 0 itim CJ % Name of Facility Street _ / q/& 0, ,a &8 ,Vd< City- County r- Zip Code � c�h -i-h- -Ii1• 55°g c -- Signal-We Title , Phone #4,5-/- s /-dZ) _ P 2J y3 r- (11-131 Fluoride Chemical Used . , Raw Water Fluoride Concentration Water Source 2141/ i wm-l-ti G (9`t7 mg/1 I j / rr "7 7.717( Amount of Soon • 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 . 4 5 6 - 8 9 • 10 11 ° 12 • .• 13 . 14 . 15 . 16 17 • 18 - ' 8 19 _ 20 21 _. 22 23 24 • 1. , 25 26 27 28 29 30 31 .777 777 )7( ,-) ®C5 ,----. 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 Fl HE-00818-02 IC 140-0013