Michigan Department Of Environmental Quality

MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALITY OFFICE OF DRINKING WATER AND MUNICIPAL ASSISTANCE ANNUAL PUMPAGE/USAGE REPORT FOR COMMUNITY WATER SUPPLY Issued under authority of 1976 PA 399, MCL 325.1001 et al., and Administrative Rules, as amended. Failure to submit this form is a violation of Act 399 and may subject the water supply to enforcement penalties.

Administrative Rule R 325.11504 states in part that “…each Type I public water supply which does not submit a monthly operation report shall submit an annual report … of water pumpage and water use.” Complete this form and return it to the appropriate Department of Environmental Quality district office by March 31 following the year covered by the report. For district office addresses, visit www.michigan.gov/deq and click on Locations. Add additional sheets as needed.

Water Supply: WSSN: County:

MONTHLY PUMPAGE/USAGE Total Monthly Well No. Well No. Well No. Well No. Calendar Pumpage/Usage Capacity in gpm Capacity in gpm Capacity in gpm Capacity in gpm in million gallons Year in gallons JANUARY

FEBRUARY

AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

Comments: Total Yearly Pumpage/Usage Average Daily Pumpage/Usage (Total Yearly Pumpage / 365)

Maximum Daily Pumpage And Date Pumpage Date

Minimum Daily Pumpage And Date Pumpage Date

Name/Title:

Signature: Date:

EQP 2007 (Rev. 7/2014)