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ATTACHMENT C- INFORMATION SHEET C-12 MODEL MONITORING AND REPORTING PROGRAM STATE WATER RESOURCES CONTROL BOARD ORDER WQ 2014-0153-DWQ GENERAL WASTE DISCHARGE REQUIREMENTS FOR SMALL DOMESTIC WASTEWATER TREATMENT SYSTEMS 2. An evaluation of the performance of the wastewater treatment facility, including discussion of capacity issues, nuisance conditions, system problems, and a forecast of the flows anticipated in the next year. A flow rate evaluation as described in the General Order (Provision E.2.c) shall also be submitted. 3. If disinfection with ultraviolet light is performed, describe disinfection system maintenance activities performed in the calendar year. The description shall address inspections performed, lamp bulb replacement, lamp sleeve cleaning, and manufacturer recommended maintenance activities. 4. A discussion of compliance and the corrective action taken, as well as any planned or proposed actions needed to bring the discharge into compliance with the NOA and/or General Order. 5. A discussion of any data gaps and potential deficiencies/redundancies in the monitoring system or reporting program. 6. The name and contact information for the wastewater operator responsible for operation, maintenance, and system monitoring. 7. A groundwater monitoring report prepared by a California licensed professional. This report may be prepared separately from the rest of the Annual Report. The report shall contain an analysis of groundwater data collected during the year. The analysis shall include a description of the sample events, copies of the field logs, purge method and volume, groundwater elevation and trend, a groundwater elevation map for each sample event, summary tables showing results for parameters measured, comparison of groundwater quality parameters to standards in the NOA, chain-of-custody forms, calibration logs for field equipment used, and a general evaluation of any impacts the wastewater discharge is having on groundwater quality. A letter transmitting the monitoring reports shall accompany each report. The letter shall report violations found during the reporting period, and actions taken or planned to correct the violations and prevent future violations. The transmittal letter shall contain the following penalty of perjury statement and shall be signed by the Discharger or the Discharger's authorized agent: "I certify under penalty of law that I have personally examined and am familiar with the information submitted in this document and all attachments and that, based on my inquiry of the those individuals immediately responsible for obtaining the information, I believe that the information is true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment." The Discharger shall implement the above monitoring program as of the date of this MRP. Ordered by: NAME, Executive Officer DATE September 23, 2014