PWS ID# NAME

SANITARY WORK SURVEY CHECKLIST

DISCRIPTION CURRENT VALUE PERMITTED VALUES NOTES

ADMINISTRATIVE
Classification / Source SW,GW,GWUDISW
Classification / PWS C,NTNC,NC
Owner Tribal, Private
Mailing address
Phone number
Facility location and directions
County
Surveyor
Survey Date 1/0/00
Past survey date 1/0/00
Past surveyor
GWUDISW score
Assessment date 1/0/00
POINTS OF CONTACT
Owner & or legally responsible
Title
Name
Business phone #
Emergency phone#
Fax number
E-mail address
Address line 1
Address line 2
City
State
Zip
Utility board chair or operator
Title
Name
Business phone #
Emergency phone#
Fax number
E-mail address
Address line 1
Address line 2
City
State
Zip
Operator(s):
Name
Certificate Type
Certificate date
Name
Certificate Type
Certificate date
Name
Certificate Type
Certificate date
Name
Certificate Type
Certificate date Non certified operators
Name
Certificate Type
Certificate date
Person contacted for survey
Phone No.
IHS team member
Phone No. comments
 DISCRIPTION CURRENT VALUE PERMITTED VALUES NOTES
SERVICE DATA
Service areas 1 residential area, school, day care center, tribal building, medical facility,
Service areas 2 casino, store, service station, restaurant, recreation area,
Service areas 3 hotel/motel, campground, mobile home park, other
first month last month
Period open year-round or seasonal
If seasonal, from 1st month to last month leave blank if year-round
Period qualified as PWS year-round or seasonal
If seasonal, from 1st month to last month leave blank if year-round
Water Usage gpd
Water Loss gpd
Population / High
Population / Low
Population / Average
Water usage per person/day gpd
Water sold to (consec system) Name or NA
PWSID #
No. of Connections
Residential
Commercial
Is Water: metered?
unmetered?
both metered & unmetered?
Any Service Interruptions last year? Yes, No, NI
Any Serv. Interuptions in last 5 yrs? Yes, No, NI
When
Where
Why
Duration
Comments

SOURCE DATA
Any SWP? Yes, No, NI
SWP Agency & Date
Consec. System? If N, go to Wells Yes, No
Water purchased from (name, PWS#)
Source SW,GW
Another PWS consec. to this? Yes, No
If Yes, give Name and PWS ID#
If hauler, hauls only water? Yes, No
Is there disinfec. res. at delivery? Yes, No
How do they disinfect their tank?
How often ?
What other customers do they have?
Backflow prevent on tank's hose? Yes, No
Are dust caps on the fill points? Yes, No
Does PWS have booster disinfect? Yes, No
Wells? If N, go to Springs Yes, No
Nature of recharge area
How is recharge area access cont?
Sources of polution, Abandoned Wells? Yes, No
Other sources, describe

Formation and/or rock type

Geologic name
Comments
Current and Abandoned Wells Well #1 Well #2 Well #3 Well #4 Well #5
Name and or Number
Status
Latitude
Longitude
Housed?
Pitless adapter
Pit Vault present?
working drain or sump pump? Y,N
open or closed?
covered? Yes, No
Date drilled
Well depth (ft.)
 DISCRIPTION CURRENT VALUE PERMITTED VALUES NOTES
Hole size (in.)
Casing size inches
depth feet
12" above ground? Yes, No
Perforations size
type
total #
depth
depth
Pump set at, depth
type
rate of flow
Well Head properly sealed ? Yes, No
subject to flooding ? Yes, No
Vent facing downward ? Yes, No
screened? Yes, No
18" above ground ? Yes, No
Raw wtr sample tap present ? Yes, No
Where is it ?
Comments
Springs, etc.?, If N, go to Streams Yes, No
Name/number
Latitude
Longitude
Describe supply intake
Yield (gpm)
Subject to flooding? Yes, No
Subject to surface infiltration? Yes, No
How is access controlled?
Sources of potential pollution
Nature of recharge area
Seasonal cond change wtr quality? Yes, No
If yes, describe
How is collection chamber constructed?
Streams, If N, go to Reservoir Yes, No
Name/number
Intake Latitude
Intake Longitude
Flow rate (gpm)
Describe supply intake
Nature of watershed
How is watershed protected?
Freq. of intake inspection
Date last inspected
Sources of potential pollution
Surface treatment of contained wtr? Yes, No
Multiple intakes at different levels? Yes, No
If yes, describe
Intake(s) depth or elevation intake #1 depth or elev intake #2 depth or elev intake #3 depth or elev intake #4 depth or elev

Are the intakes screened? Yes, No

Is area around intake restricted? Yes, No
Radius (ft.)
Seasonal or other cond's change Yes, No
wtr quality? If yes, describe
Comments
 DISCRIPTION CURRENT VALUE PERMITTED VALUES NOTES
Reservoirs/Lakes Yes, No
Name/number
Intake Latitude
Intake Longitude
Area sq miles or acres
Volume ac ft
Describe supply intake
Nature of watershed
How is watershed protected?
Freq. of intake inspection
Date last inspected
Sources of potential pollution
Surface treatment of contained wtr? Yes, No
Multiple intakes at different levels? Yes, No
If yes, describe
Intake(s) depth or elevation intake #1 depth or elev intake #2 depth or elev intake #3 depth or elev intake #4 depth or elev

Are the intakes screened? Yes, No

Is area around intake restricted? Yes, No
Radius (ft.)
Seasonal or other cond's change Yes, No
wtr quality? If yes, describe
Comments
TRANSMISSION/RAW H2O
Name or designation
Point of origin
Point of termination
Date in service
Length
Diameter
Material
Pressure range
Flow Rate(gpm)
Controls and/or PRV's (describe)
ARV's (number)
Condition
Pump station subject to flooding? Yes, No
If yes,describe causes, natural or other
Any Breaks in last 2 Yrs.? Yes, No
If yes, describe
Pumps Pump number Type/Material Standby Flow Rate Condition

Comments
TREATMENT DATA
TP Latitude
TP Longitude
Directions to Treatment Plant
TP schematics updated?
Date plant on line
Latest Modification
Daily Output (gpd):
Design
Average
Max.
Pre-treatment chem.

Dosage

Purpose

Where injected

Plant subject to flooding? Yes, No

Use Acrylamide / epichlorohydrin? Yes, No
Acrylamide = 0.05% dosed at 1ppm Yes, No
Epichlorohydrin = 0.01% dosed at 20ppm Yes, No
Doc or Cert from Manuf to support this? Yes, No
 DISCRIPTION CURRENT VALUE PERMITTED VALUES NOTES
Water safety controls
Will the plant automatically shut down if :
a chemical feed pump shuts off ? Yes, No
turbidity is high ? Yes, No How high? NTU
disinfectant residual is low ? Yes, No How low? mg/L
line pressure is low ? Yes, No How low? psi
storage tank level is low ? Yes, No How low? feet
Coagulation and Flocculation Yes, No Chemicals and other flocculants
Chemical coagulant added aluminum sulfate (alum), ferric chloride, ferric sulfate, ferrous sulfate, cationic polymer,
anionic polymer, nonionic polymer, bauxite, calcium oxide, bentonite, calcium carbonate,
carbon dioxide, sodium silicate, other
Equipment
Rapid mix unit mechanical mixer, injection mixer, in-line blender mixer, others
Flocculation tanks hydraulic flocculator, mechanical flocculator
Clarification/Sedimentation Yes, No Processes
Type of process
horizontal-flow (rectangular basins), horizontal-flow (round basins), inclined-plate sedimentation, up-flow
solid-contact sedimentation, tube sedimentation, dissolved air flotation, upflow sludge blanket
Filtration Yes, No Processes
Number of filters Conventional filtration: dual or mixed media filter, single media filter, slow sand filter, rapid sand filter,
green sand filter. Direct filtration (not preceeded by sedimentation).
For filters in series, list from upstream to
downstream. Packaged filter unit and pressure filters are conventional if contain or preceeded by coag, floc, & sed
Process Manufacturer name and model Final filter barrier
Note with * those that are in parallel NA X
If applicable, list manufacturer name and
model.
Note final filter barrier with "X"

Average length of filter runs hours or minutes

Maximum filter loading rate gpm/ft2
Filter media material Media Depth Media material
for conventional/direct filters fine sand, coarse sand, anthracite coal, garnet
Support gravel is not considered part of the filter media.
Activated carbon for taste, odor or organic substance removal

Comments
For conventional or direct filtration: This section is NA if there is no conventional or direct filtration or if the final filter barrier is not conventional or direct filtration.
If so, skip to the "Other types of filtration" section below.

Turbidity measurement Note: For 2 or less filters, a single CFE (combined filter effluent)
Does each filter have an IFE turbidimeter? Yes, No turbidimeter may be used.
Are there alarms on each filter? Yes, No Date of last IFE
Filter number IFE turbidimeter type and model number Alarm set point, NTU turbidity calibration
1
2
3
4
Is there a CFE turbidimeter? Yes, No
CFE turbidity type and model number
Date of last CFE turbidimeter calibration
Frequency of turbidimeter calibrations?
Finished water CFE turbidity by PWS. NTU
Finished water CFE turbidity by surveyor NTU
Any violations of finished water turbidity
in the last year? Yes, No
Comments

Has the PWS been consistently meeting the CFE turbidity requirements (0.5 NTU 95% of each month, not to exceed 5 NTU) ? Yes, No
Effective 1/1/05 (0.3 NTU 95% of each month, not to exceed 1NTU)

Are IFE (or CFE for 2 or less filter) turbidities measured continuously and recorded every 15 minutes? Yes, No
Are these records kept for the last 3 yrs? Yes, No
 DISCRIPTION CURRENT VALUE PERMITTED VALUES NOTES
Skim the last 12 months IFE (or CFE) turbidity records. Answer the following questions, note dates and make copies of any records where the answers are "yes".
1. Did any single filter IFE (or CFE) exceed 1.0 NTU in 2 consecutive 15-minute readings? Yes, No If yes, list dates
If so, did they report to EPA and do a filter profile, if required, i.e. >10,000 ? Yes, No, NA & copy record
If this occurred 3 months in a row, did they conduct a filter self-assessment? Yes, No

2. Did any single filter IFE (or CFE) exceed 2.0 NTU in 2 consecutive 15-minute readings? Yes, No If yes, list dates
If this occurred 2 months in a row for the same filter, did they report to EPA and have & copy record
a CPE performed? Yes, No

Filter Backwash

Backwash determining factors

Turbidity "X" those that apply
Head loss
Auto setting
Time
Other
Material used for backwash Air Scour, Finished water, Raw water
Does PWS do filter to waste before
putting filters back on line ? Yes, No
Gallons/Backwash gallons
Loss of finished water to backwash percent
Turbidity measured after flush? Yes, No
If yes, value NTU
Backwash Recycle
Is backwash water, thickener supernatant,
or sludge dewatering liquids recycled ? Yes, No
If yes, which ones ?

If yes, describe where recycle enters

treatment process (observe during survey)

Recycle practices
avg & max times/flows of backwashes, and recycle treatment/equalization (chemical addition,
If yes, are records kept of recycle hydraulic loading rates) (Required after June 8, 2004)
practices ? Yes, No
Comments
Methods
Residuals Disposal Yes, No Discharge to: holding pond, holding pond then to raw water, raw water, sanitary sewer
Method Mechanical dewatering. On-site disposal. Land application. Solids composting.

If discharging to a holding pond then to raw

water, does system have a NPDES permit? Yes, No
 DISCRIPTION CURRENT VALUE PERMITTED VALUES NOTES
Other types of filtration (not conventional or direct)
Number of filters If Bag/Cartridge
For filters in series, list from upstream to Filter Manufacturer name and model Final filter barrier absolute pore size
downstream
Note with * those that are in parallel X
List manufacturer name and model
Note final filter barrier with "X"
Is there a CFE turbidimeter? Yes, No
CFE turbidimeter type and model number
Date of last CFE turbidimeter calibration
Frequency of turbidimeter calibrations?
Finished water CFE turbidity by PWS. NTU
Finished water CFE turbidity by surveyor NTU
Has the PWS been consistently meeting the CFE turbidity requirements (1 NTU 95% of each month, not to exceed 5 NTU) ? Yes, No
Comments
Diatomaceous Earth Filters - additional questions
Average length of filter runs
Backwash determining factors
Turbidity "X" those that apply
Head loss
Auto setting
Time
Other
Bags / Cartridges - additional questions
#1 #2 #3 #4
What is the absolute pore size of each ?
What is the replacement frequency ?
Working press gauges before & after filters Yes, No
Does the PWS keep records of monitoring
the pressure drop across the filters? Yes, No
Membranes - additional questions
Membrane class micro, ultra, nano, etc.
Membrane type hollow fiber, spiral wound, tube, etc.
Age of membranes
Is prefiltration present? Yes, No
Redundancy?
Is there verification from the manufacurer
that challenge testing has been performed
on the membrane unit? Yes, No
How often are direct integrity tests done? e.g. pressure or vacuum applied
What cont. indirect integrity test is done? e.g. turbidity of finished water
What specific trigger is used when indirectly
testing integrity? e.g. NTU limit triggering action
How are membranes cleaned ?
If cleaned chemically, what chemicals
are used ?
What becomes of the used chemical
cleaning solutions?
Any cross connections between
cleaning chemicals and finished water? Yes, No
When are membranes cleaned ?
Comments
 DISCRIPTION CURRENT VALUE PERMITTED VALUES NOTES
Special Processes for turbidity Yes, No Processes
or other problems reverse osmosis, electrodialysis, activated alumina,
Process POE & POU devices, ferric hydroxide and ion exchange for arsenic, others
Location in treatment train
Process
Location in treatment train
Other Treatment Processes Yes, No Processes
Process aeration, packed tower aeration, ion-exchange softening,
Location in treatment train lime soda ash softening, copper sulfate treatment, powdered activated carbon
Process
Location in treatment train
pH Adjustment Yes, No Treatments
Treatment calcium carbonate, carbon dioxide, hydrochloric acid, calcium oxide,
Location in treatment train calcium hyhdroxide, sodium hydroxide, sulfuric acid, other

Additional Treatments See below: Treatment Objectives and Processes and the attached table in the spread sheet

Disinfection Yes, No Methods

Method - Chemical disinfecton gaseous chlorine, calcium hypochorite, sodium hypochlorite, chlorine dioxide, chloramines,
Dosage ozonation, other
Point of application
Standby equipment available? Yes, No
in working order? Yes, No
Spare parts in stock? Yes, No
Emergency power for disinfection equip? Yes, No
Any disinfect. interruptions last year? Yes, No
If yes, describe
Is the facility subject to flooding? Yes, No
Residual detectable at end of dist. Syst.? Yes, No
Comments
Where does the PWS measure disinfectant residual
for compliance with the SWTR requirement
that it be >= 0.2 mg/L at POE ?
How is it measured? continuous sample or grab sample
Equipment manufacturer and model #
Free chlorine residual at POE as measured
by PWS during the survey mg/L
Free chlorine residual at POE as measured
by surveyor during the survey mg/L
Method - UV disinfecton
Point of application
UV Manufacturer and model number
Is there:
Monitor / alarm for flow rate? Yes, No
UV sensor to measure irradiance? Yes, No
UV lamp status alarm? Yes, No
UV dose (mj/sq cm)?
How often is the unit cleaned and
the bulbs changed?
Are spare bulbs on hand?
 DISCRIPTION CURRENT VALUE PERMITTED VALUES NOTES
Disinfection Profiling (Nontransient Systems)
Did they receive an exemption from
profiling from EPA? Yes, No
If not exempted, did profiling start on or
before 7/1/03 (systems serving <10,000
but >500) or 1/1/04 (smaller systems)? Yes, No
If not, indicate when profiling started. Date
Skim the disinfection profile (graphic, speadsheet etc.) to ensure that weekly log inactivation calculations are being made.
Note the lowest monthly avg. log Giardia inactivation from the profile.
Month Month
Monthly avg. log Giardia inactivation Value
This value should not be less than the logs inactivation ** needed per the CT calculation below
Did the PWS make a significant change
(new disinfectant, new location, etc.) to
disinfection practices after 7/1/2004? Yes, No
Date of change Date
Was EPA consulted before making change? Yes, No
Describe the change

Stage 1 DBPR Monitoring Plan (Nontransient Systems)

Is there a plan available at the PWS for monitoring
DBPs and disinfectant residuals per regs? Yes, No
What types of Maximum Residual Disinfectant Levels MRDLs for:
(MRDLs) are measured? free chlorine, chloramines, or chlorine dioxide?
If using conventional filtration:
Is there a plan available at the PWS for
monitoring DBP precursors? Yes, No
Is it up to date reflecting the current
distribution system? Yes, No
If using conventional filtration as the final barrier:
How does the PWS comply with the DBP
precursor removal requirements?
Complies by one of the following three
By meeting alternative compliance criteria (ACC)
By meeting Step 1 TOC removal requirements
By meeting EPA approved Step 2 alternative minimum TOC removal requirements
 DISCRIPTION CURRENT VALUE PERMITTED VALUES NOTES
Compliance with the SWTR 3-log Must be achieved before or at first customer or user.
Giardia and 4-log virus reduction Note - Compliance with Crypto 2-log removal requirements determined by
requirements. meeting monthly IESWTR/LT1ESWTR turbidity requirements.
Final Filtration Barrier type of filtration
Logs removal credited for that barrier:
for Giardia =
for viruses =
**Logs inactivation needed
for Giardia =
for viruses =
Treatment Technique Inactivation Determination
1. If the PWS does their own daily or weekly CT inactivation calculation, verify the accuracy
of those calculations. If accurate, indicate the lowest Total logs Giardia and virus inactivation
calculated during the past year for all segments where CT credit is used:
Total logs Giardia inactivation
from all segments =
Total logs virus inactivation
from all segments =
Are Giardia and virus total treatment
requirements ** met? Yes, No

FILTRATION CREDITS FOR MICROBIAL REMOVAL, TO MEET SWTR, IESWTR AND LT1ESWTR**
(systems consistently meeting the CFE turbidity limits in the table below, and the operational design requirements outlined in this policy, are granted the Logs removal credit
in the table below.)

Filtration Treatment Technology Combined Filter Maximum Logs of Credit for Physical Minimum Logs of
Effluent (CFE) Tubidity Removal Inactivation Needed
(95% Monthly / Max) By Disinfection
NTU Cryptosporidium Giardia Viruses Giardia Viruses
Conventional *** 0.3 / 1 >2 2.5 2.0 0.5 2.0
Direct *** 0.3 / 1 >2 2.0 1.0 1.0 3.0
Slow Sand 1/5 >2 2.0 2.0 1.0 2.0
Diotomaceous Earth 1/5 >2 2.0 1.0 1.0 3.0
Reverse Osmosis 0.3 / 1 >2 >3.0 3.0 0 1.0
Nanofiltration 0.3 / 1 >2 >3.0 3.0 0 1.0
Ultrafiltration 0.3 / 1 >2 >3.0 0 0 4.0
Microfiltration 0.3 / 1 >2 >3.0 0 0 4.0
Pretreatment + Bag or Cartridge, B/C* 1/5 2 2.0 0 1.0 4.0
Conventional followed by B/C 0.5 / 5 2 2.5 2.0 0.5 2.0

*See policy for description of adequate pretreatment for SW and for GWUDISW using B/C Filtration

**Additional types of alternative filtration should be evaluated on a case-specific basis. 95th percentile and maximum turbidity values will be no more than 1 NTU and 5
NTU, respectively, for alternative filtration technologies, unless different site specific values are assigned. All Ntu rounding shall be in accordance with EPA established
policy. Also, these filtration credits do not apply to point-of-use devises.

***Conventional and direct filtration also have requirements for monitoring of individual filter effluent turbidity (IFE). See IESWTR and LT1ESWTR.
 DISCRIPTION CURRENT VALUE PERMITTED VALUES NOTES
OR
2. Do a conservative calculation:
For each inactivation segment where credit is desired for Giardia and virus inactivation:
Segment #1
Disinfectant free chlorine, chlorine dioxide, chloramine, ozone
Lowest disinfectant residual, mg/L
and where measured location
Water pH (highest):
Water Temperature (lowest): degrees centigrade
Maximum hourly flow rate gpm
Vessel pipe, clearwell, tank, etc.
Volume gallons calculate volume using minimum operating height of vessels
Baffle factor
Logs Giardia inactivation
Logs virus inactivation
Segment #2
Disinfectant free chlorine, clorine dioxide, chloramine, ozone
Lowest disinfectant residual, mg/L
and where measured location
Water pH (highest):
Water Temperature (lowest): degrees centigrade
Maximum hourly flow rate gpm
Vessel pipe, clearwell, tank, etc.
Volume gallons calculate volume using minimum operating height of vessels
Baffle factor
Logs Giardia inactivation
Logs virus inactivation
Segment #3
Disinfectant free chlorine, chlorine dioxide, chloramine, ozone
Lowest disinfectant residual, mg/L
and where measured
Water pH (highest):
Water Temperature (lowest): degrees centigrade
Maximum hourly flow rate gpm
Vessel pipe, clearwell, tank, etc.
Volume gallons calculate volume using minimum operating height of vessels
Baffle factor
Logs Giardia inactivation
Logs virus inactivation
Total logs Giardia inactivation
from all segments =
Total logs virus inactivation
from all segments =
Are Giardia and virus total treatment
requirements ** met? Yes, No
 DISCRIPTION CURRENT VALUE PERMITTED VALUES NOTES
Fluoridation? Yes, No
Is sys adjusting natural fluoride level? Yes, No
Chemicals used? sodium fluoride, sodium fluorosilicate, fluorosilicic acid
Fluoride tested & recorded daily? Yes, No
Results reported to who? CDC, I.H.S., State, other
Monthly sample splitted? Yes, No
Operator trained in fluoridation? Yes, No
Feed pump interlocked to? plant power, high service pump, flow meter, raw water pump, control valve, flow switch
Feed pump has secondary flow control via? flow switch, pressure device
Fluoride injection system has
anti-siphon protection at: pump discharge, injection point, other, none
If fluorosilicic acid used:
Acid injected at full strength (23-25%)? Yes, No
7 day supply connected to feed pump? Yes, No
Scales used to track usage? Yes, No
Comments
Treatment Objectives/Processes See attached table in the spread sheet
Facility Treatment Objective Treatment Process Treatment Code

Comments

TRANSMISSION/TREATED H2O
Service area or designation
Date in service
Point of origin
Point of termination
Length
Diameter
Material
Pressure range
Controls &/or PRV's Yes, No, describe
ARV's Yes, No
Condition
Flow rate (gpm)
Any breaks last 2 years? Yes, No
If yes, describe
Is pump station subject to flooding? Yes, No
Pump name / number Type Standby Flow Rate Condition

Comments
 DISCRIPTION CURRENT VALUE PERMITTED VALUES NOTES
STORAGE DATA, TREATED WATER
CLEARWELL SIZE (gallons)
TANKS AND CISTERNS
Tank #1 Tank #2 Tank #3 Tank #4 Tank #5
Tank Name and / or number
Latitude
Longitude
Style and material
Capacity (gallons)
Total days supply
Date in Service
Subject to flooding
Structurally Sound
Well maintained ?
Overflow lines turned down ?
covered and screened ?
3 diam above ground ?
Air vents turned down ?
covered and screened ?
Drain and cleanout lines
turned down ?
covered and screened ?
3 diam above ground ?
Can tank be isolated ?
Storage covered/enclosed ?
Safety measures
Tank last cleaned ?
Disinfected after repair ?
Community served
Comments
DISTRIBUTION DATA
Lines Origin Material Inside Diameter Length
Main Lines

Distribution Lines

Service Lines

Any asbestos pipe in dist system? Yes, No

Sufficient cover to prevent freeze? Yes, No
Has PWS had prob. with freeze ? Yes, No
Main line material select to resist
corros, electrolysis, deterioration? Yes, No
Backflow prev. on stock tanks? Yes, No, NA
Any dead ends ? Yes, No
How many ?
Any plans to elim. dead ends ? Yes, No
Plans to add/test backflow prev.
in vulnerable portion of dist.sys? Yes, No
Is there a flushing schedule ? Yes, No
Is the water system looped ? Yes, No
Comments
Pressure Zones Controls "X" those that apply
Area Pressure range Auto Manual Remote

Is pressure at least 20 psi in distrib.

system under all conditions? Yes, No
Comments
 DISCRIPTION CURRENT VALUE PERMITTED VALUES NOTES
CROSS CONNECTION CONTROL
Type Size Last Tested

Date of operator training

Interconnection with another system? Yes, No
If yes, describe
Comments

GENERAL MAINTENANCE
Is there an adequate maint. program? Yes, No
If yes, describe

Are gate valves exercised? Yes, No

Are as builts updated ? Yes, No
How often is system flushed?
Formal plan, routine insp.pumps & motors? Yes, No
Conducted by PWS or qual pump contr?
Written plans for preventive maintenance? Yes, No
Describe
Is there log of breaks and repairs? Yes, No
Any tracking of spare parts? Yes, No
Describe
Prompt delivery from suppliers ? Yes, No
Comments
SAFETY AND SECURITY
Written procedures for somone injured? Yes, No
Any written plan for system emergencies? Yes, No
Wells: fenced ? Yes, No
Locked ? Yes, No
Frequency of patrol ?
Pump houses fenced ? Yes, No
Locked ? Yes, No
Frequency of patrol ?
Chemical storage fenced ? Yes, No
Locked ? Yes, No
Frequency of patrol ?
Treatment plants fenced ? Yes, No
Locked ? Yes, No
Frequency of patrol ?
Storage tanks fenced ? Yes, No
Locked ? Yes, No
Frequency of patrol ?
Manholes/vaults fenced ? Yes, No
Locked ? Yes, No
Frequency of patrol ?
Springs & Infiltration Galleries fenced ? Yes, No
Locked ? Yes, No
Frequency of patrol ?
Stream intakes fenced ? Yes, No
Locked ? Yes, No
Frequency of patrol ?
Reservoirs/Lakes intakes fenced ? Yes, No
Locked ? Yes, No
Frequency of patrol ?
Access to fac restrict to auth persons? Yes, No
Comments
 DISCRIPTION CURRENT VALUE PERMITTED VALUES NOTES
CONFINED SPACES
Any confined space policy? Yes, No
Has there been training? Yes, No
Is adequate equipment available? Yes, No
Operator familiar with OSHA policy? Yes, No
Comments
CHLORINE SAFETY NA Comments
Is chlorine safety training ongoing? Yes, No
Are warnings posted on doors? Yes, No
Do doors open outward? Yes, No
Do doors open to the exterior? Yes, No
Crash bars and viewports on doors? Yes, No
Is there audible alarm? Yes, No
Is chlorine feed and storage isolated? Yes, No
Is chlorine room well ventilated? Yes, No
Are chlorine cylinders restrained? Yes, No
Are breathing units available? Yes, No
Where is breathing apparatus stored?
Staff trained in breathing apparatus? Yes, No
Are chlorine leak kits available? Yes, No
Staff trained in leak kits? Yes, No
Comments
CHEMICAL SAFETY NA Comments
Staff understands chem. handling? Yes, No
Chemicals properly stored? Yes, No
Oxid., corro., chems properly kept? Yes, No
Flammables stored properly? Yes, No
Chem. use and storage areas ventiled? Yes, No
Safety equip. provided & required? Yes, No
Staff trained in chem. handling? Yes, No
Staff familiar with the MSDS sheets? Yes, No
Storage areas separated from TP? Yes, No
Is the fire department informed? Yes, No
Comments
EMERGENCY RESPONSE
Back-up power available for:
Source? Yes, No, NA
Raw water Transmission? Yes, No, NA
Disinfection? Yes, No, NA
Treated water transmission? Yes, No, NA
Distribution? Yes, No, NA
Source of back-up power? generator, local electrical supplier
Does it provide 100% of power need? Yes, No, NA
Is back-up power exercised at least 30min? Yes, No, NA
Is the local power utility informed? Yes, No, NA
Describe emergency response plans
to include handling ruptures,
chem overfeed, and terrorism.
Is plan in place to provide water
in the event of an emergency? Yes, No
If yes, when was it last updated?
Describe
Comments
 DISCRIPTION CURRENT VALUE PERMITTED VALUES NOTES
MONITORING & RECORDS
Number of bacteria samp per month
Sample site plan submitted to EPA? Yes, No
Is sampling procedure adequate? Yes, No
Operator knows about MCL & TC+? Yes, No
Are extra sample bottles at hand? Yes, No
Are records retained in the premises? Yes, No
Are records current? Yes, No
Are records available to surveyor? Yes, No
Any data manag. Sys for reg. & O&M ? Yes, No
If yes, describe
Any reports of waterborne disease? Yes, No
If yes, give dates and describe each
report within the last two years. Date Type Agency Action System Response

Comments

SAMPLES TAKEN DURING SURVEY

Type Results

Appropriate test kits and reagents

available for daily monitoring?
What certified lab does the testing?
 PWS NAME
DATE
PWSID #

SANITAY WORK CHECK DETAILING

Sanitary Survey Abreviations:Y=Yes, N=No, NI = No Information, NA = Not Applicable, C=Community, NC=Non-community, NTNC=non-transient non-community
(Numbered notes are at the end of the report)

ADMINISTRATIVE DATA Surveyor: 0

Water System No. (PWS ID#) 0 PWS Name 0 Date: 12/30/1899
Classification / Source 0 Classification / PWS 0 Owner 0
Mailing address 0 Phone # 0
Facility location and directions 0 County 0
Prior survey date ### GWUDISW score 0
Past surveyor 0 Assessment date ###
POINTS OF CONTACT
Owner or person legally responsible Title 0
Name 0 Business ph# 0
Address Line 1 0 Emergency ph# 0
Address Line 2 0 Fax 0
City 0 State 0 Zip 0 E-mail 0
Utility Board Chair or Operator Title 0
Name 0 Business ph# 0
Address Line 1 0 Emergency ph# 0
Address Line 2 0 Fax 0
City 0 State 0 Zip 0 E-mail 0
Operator(s)
Operator name 0 Operator name 0
Certification type 0 Certification type 0
Certif. date 0 Certif. date 0
Operator name 0 Operator name 0
Certification type 0 Certification type 0
Certif. date 0 Certif. date 0
Operator name 0 Non certified operators 0
Certification type 0 0
Certif. date 0 0
Person contacted for survey 0 Phone 0
IHS Team Member 0 Phone 0
Comments 0
 PWS NAME
DATE
PWSID #

SERVICE DATA
Service Area 1 0
Service Area 2 0
Service Area 3 0
Period open year-round or seasonal Fr 0 Period qualified From 0 Water usage (gal/day) 0
0 To 0 as PWS 0 To 0 Water lost (gal/day) 0
Population High 0 Water usage per person/day Water sold to Name 0
Low 0 Avg. daily 0 (Community systems only) 0 (consec. sys) PWS ID# 0
Number of Is water: metered? 0
Service Connections 0 Number of service Residential 0 unmetered? 0
connections by type Commercial 0 both metered & unmetered? 0
Any service
interruptions? During the past year? 0 During the past 5 years? 0
When 0
Where 0
Why 0
Duration 0
Comments 0

SOURCE DATA Complete only those sections that apply to the system and check "NA" box for others Include map or drawing of distribution sys.
Has there been a source water protection survey? 0
If yes, provide agency and date 0 0

Consecutive Systems? 0
Water purchased from 0 PWS ID# 0 Source type 0
Is there another PWS consecutive to this one? 0 If yes, name 0 PWS ID# 0
If a water hauler is involved: a) Do they haul only water? 0 b) If their source is a SW, is a disinfection
residual remaining at time of delivery? 0
c) How do they disinfect their tank? 0 d) How often do they disinfect their tank? 0
e) What other customers do they have? f) Is there backflow prevention on tank's hose? 0
0 g) Are dust caps on the fill points? 0
Does this PWS have booster disinfection? 0

Wells 0
Nature of recharge area 0 How is access to recharge area controlled? 0
Possible sources of pollution: Abandoned wells? 0 Describe any other sources 0
Formation and/or rock type (if available) 0 0
Geologic name of aquifer 0
Comments 0
 PWS NAME
DATE
PWSID #

Current and Abandoned Wells (Include wells that are candidates for abandonment) Copy this page as needed for additional wells.
Well Name or # 0 0 0 0 0
Status 0 0 0 0 0
Location Latitude 0 0 0 0 0
Longitude 0 0 0 0 0

Housed? 0 0 0 0 0
Pitless adapter? 0 0 0 0 0
Pit Vault
Present? 0 0 0 0 0
Working drain or sump pump? 0 0 0 0 0
Open or closed? 0 0 0 0 0
Covered? 0 0 0 0 0
Date drilled 0 0 0 0 0
Well depth (ft.) 0 0 0 0 0
Hole size (in.) 0 0 0 0 0
Casing
Size 0 0 0 0 0
Depth 0 0 0 0 0
12" above ground? 0 0 0 0 0
Perforations
Size 0 0 0 0 0
Type 0 0 0 0 0
Total # 0 0 0 0 0
Depth 0 0 0 0 0
Depth 0 0 0 0 0
Pump
Set at? 0 0 0 0 0
Type 0 0 0 0 0
Rate of flow (gpm) 0 0 0 0 0
Well Head
Properly sealed? 0 0 0 0 0
Subject to flooding? 0 0 0 0 0
Vent
Facing downward? 0 0 0 0 0
Screened? 0 0 0 0 0
18" above ground? 0 0 0 0 0
Raw water sampling tap
Present? 0 0 0 0 0
Where is it? 0 0 0 0 0
Include well log(s) if available.
Comments 0
 PWS NAME
DATE
PWSID #

Springs and Infiltration Galleries 0

Name/Number 0 Location: Yield, gpm 0
Describe supply intake 0 Latitude 0 Subject to
0 Longitude 0 flooding? 0
Subject to surface infiltration? 0 How is access controlled? 0
Sources of potential pollution Nature of recharge area 0
0 Are there seasonal or other conditions which change water quality? 0
How is collection chamber constructed? If yes, describe 0
0 0
Comments
Streams 0
Name/Number 0 Location: Rate of
Describe supply intake 0 Latitude 0 flow
Longitude 0 gpm 0
Nature of watershed 0 How is watershed protected? 0
Frequency of intake inspection 0 Sources of potential pollution 0 Is there surface treatment
Date of last inspection 0 (nature/distance from intake) of contained water? 0
Are there multiple intakes at different levels? 0 Are the intakes Is the area around the intake restricted? 0
If yes, describe 0 screened? 0 Radius (ft.) 0
Intake(s) depths or elevations : Intake #1 0 Intake #2 0 Intake #3 0 Intake #4 0
Are there seasonal or other conditions which change water quality? 0
If yes, describe 0
Comments 0
Reservoirs and Lakes 0
Name/Number 0 Location: Area 0
Describe supply intake 0 Latitude 0
Longitude 0 Volume 0
Nature of watershed 0 How is watershed protected? 0
Frequency of intake inspection 0 Sources of potential pollution 0 Is there surface treatment
Date of last inspection 0 (nature/distance from intake) of contained water? 0
Are there multiple intakes at different levels? 0 Are the intakes Is the area around the intake restricted? 0
If yes, describe 0 screened? 0 Radius (ft.) 0
Intake(s) depths or elevations : Intake #1 0 Intake #2 0 Intake #3 0 Intake #4 0
Are there seasonal or other conditions which change water quality? 0
If yes, describe 0
Comments 0
 PWS NAME
DATE
PWSID #

TRANSMISSION DATA, RAW WATER

Name or designation
Date in service 0
Flow rate (gpm)
ARVs (number)
Pump station subject to flooding?
Any breaks in the last 2 years?
If yes, describe
0 Point of origin 0 Point of termination 0
Length 0 Diameter 0 Material 0 Pressure range 0
0 Controls and/or PRVs (describe) 0
0 Condition 0
0 If yes, describe causes, and identify whether natural or other: 0
0 0
0

Pumps
Pump Number Type / Material Standby Flow Rate Condition
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0

Comments 0

WATER TREATMENT DATA

Plant/Office location and directions Location: Section
0 Latitude 0 Township
Longitude 0 Range
Plant schematic readily Date plant put on line 0 Design Average Maximum
available and up-to-date? 0 Latest modifications 0 Daily output (gal./day) 0 0 0
Pre-treatment Chemicals used Dosage Purpose Where injected ? Do any chemicals
0 0 0 0 and / or additives 0
0 0 0 0 contain acrylamide or
Plant subject to flooding? 0 epichlorohydrin ?
If acrylamide or epichlorohydrin is used, does the combination of dosage & monomer level meet the following levels:
Acrylamide = 0.05% dosed at 1 ppm (or equivalent) 0 Do you have any documentation/certification from your manufacturer
Epichlorohydrin = 0.01% dosed at 20 ppm (or equivalent) 0 to support this? (Attach copy of document.) 0
Water safety controls
Will the plant automatically shut-down if: What levels
a chemical feed pump shuts-off ? 0 trigger shut-off
turbidity is high ? 0 0 NTU
disinfectant residual is low ? 0 0 mg/L
line pressure is low ? 0 0 psi
storage tank levels are low ? 0 0 feet
Coagulation Chemical coagulants added Rapid mix unit type Flocculation tank type
and Flocculation 0 0 0 0 0
2 0 0
 PWS NAME
DATE
PWSID #

Clarification/ Sedimentation 0 Type of Process (equipment used)

0
Filtration 0 Note final
Number of filters 0 filter barrier Average length of filter runs 0
If in series, list in upstream to downstream ord with "X" Maximum filter loading rate (gpm/ft2) 0 Depth of
Note filters in parallel with * Manufacturer name and model (if appropriate) Filter media material Media
Filter No. 1 0 X NA 0 0
Filter No. 2 0 0 0 0 0
Filter No. 3 0 0 0 0 0
Filter No. 4 0 0 0 0 0
0 0
Comments 0
FOR CONVENTIONAL OR DIRECT FILTRATION This section is NA if there is no conventional or direct filtration, or if the final filter barrier is not conventional
or direct filtration. If this is so, then skip to the "Other types of filtration" section below.
Turbidity measurement Alarm Set point Date of last Frequency of
Does each filter have an Filter number IFE turbidimeter type and model number NTU Calibration calibrations
individual filter effluent (IFE) 1 0 0 0 0
tubidimeter? 0 2 0 0 0
Are there alarms on each 3 0 0 0
filter? 0 4 0 0 0
Is there a combined filter effluent (CFE) turbidimeter ? 0 Note: For 2 or less filters, a single CFE turbidimeter may be used.
CFE turbidimeter type and model number 0 Finished water CFE turbidity by PWS (NTU) 0
Date of last CFE turbidimeter calibration: 0 Finished wtr CFE tubidity by surveyor (NTU) 0
Comments 0 Any finished water turbidity violations in the last year? 0
Has the PWS been consistently meeting the CFE turbidity requirements (0.3 NTU 95% of each month, not to exceed 1 NTU) ? 0
Are IFE (or CFE for 2 or less filters) turbidities measured continuously and recorded every 15 minutes ? 0 Are these records kept for the last 3 years 0

Skim the last 12 months IFE (or CFE) turbidty records. Answer the following questions, note dates and make copies of any records where the answers are "yes".
1. Did any single filter IFE (or CFE) exceed 1.0 NTU in 2 consecutive 15-min readings? 0 If yes, list dates & copy record
If so, did they report to EPA and do a filter profile, if require 0 system >10,000 pop 0
If this occurred 3 months in a row, did they conduct a filter self-assessment? 0 0
2. Did any single filter IFE (or CFE) exceed 2.0 NTU in 2 consecutive 15-min readings? 0 If yes, list dates & copy record
If this occurred 2 months in a row for the same filter, did they report to EPA and have a CPE performed? 0 0
0
Filter Backwash
Backwash determining factor(s): (check all that apply)
Turbidity 0 Auto setting 0 Material used for backwash 0
Head loss 0 Time 0 Does this PWS do filter to waste before putting filters back on line 0
Volume/ backwash (gal.) 0 % treated water lost for backwash 0
Has turbidity been measured after a flush? 0
If yes, provide most recent measurement 0
 PWS NAME
DATE
PWSID #

Backwash Recycle
Is backwash water, thickner supernatant, or sludge dewatering liquids recycled ? 0 If yes, which ones? 0 0
If yes, describe where recycle enters treatment process (observed during survey) 0
0
If yes, are records kept of recycle practices (avg & max times/flows of backwashes, and recycle treatment/equalization (chemical addition, hydraulic loading rates) 0
This is required after June 8, 2004. Comments 0

Residuals Disposal 0 If yes, describe 0

0
If discharging from a holding pond then to raw water, does the system have an NPDES permit? 0
Other types of filtration (not conventional or direct)
Number of filters 0
For filters in series, list from upstream to downstream Note filters in parallel with * Note final If Bag/Cartridge filter,
Filter Manufacturer name and model (if appropriate) with "X" absolute pore size
Filter No. 1 0 0 0 0
Filter No. 2 0 0 X 0
Filter No. 3 0 0 0 0
Filter No. 4 0 0 0 0
Is there a combined filter effluent (CFE) turbidimeter ? 0
CFE turbidimeter type and model number 0 Finished water CFE turbidity by PWS (NTU) 0
Date of last CFE turbidimeter calibration: 0 Finished wtr CFE tubidity by surveyor (NTU) 0
Frequency of turbidimeter calibrations Any finished water turbidity violations in the last year? 0
Has the PWS been consistently meeting the CFE turbidity requirements (1 NTU 95% of each month, not to exceed 5 NTU) ? 0
Comments 0
Diatomaceous Earth Filters - additional questions
Average length of filter runs 0
Backwash determining factor(s): (check all that apply)
Turbidity 0 Auto setting 0 Other 0
Head loss 0 Time 0
Bags/ Cartridges - additional questions
#1 #2 #3 #4
What is the absolute pore size ? 0 0 0 0 What is replacement frequency ? 0
Are there working pressure gauges before and after the filters? 0
Does the PWS keep records of monitoring the pressure drop across the filters ? 0
 PWS NAME
DATE
PWSID #

Membranes - additional questions

Membrane class 0 Membrane type 0 Age of membranes 0
Is prefiltration present? 0 Redundancy 0
Is there verification from the manufacturer that challenge testing has been performed on the membrane unit? 0
How often are direct integrity tests done (e.g. pressure or vacuum applied) ? 0
What continuous indirect integrity test is done (e.g. turbidity of finished water?) 0
Indicate the specific trigger used when indirectly testing integrity (e.g. NTU limit triggering actio 0
How are membranes cleaned? 0 When are membranes cleaned? 0
If cleaned chemically, what chemicals are used 0
What becomes of the used chemical cleaning solutions? 0
0
Any cross connections between the cleaning chemicals and the finished water? 0
Comments 0
Process Location in treatment train
Special Processes for turbidity 0 0 0
removal or other problems 0 0
Process Location in treatment train
Other Treatment Processes 0 0 0
0 0
Treatment Location in treatment train
pH Adjustment 0 0 0

Additional Treatments See below: Treatment Objectives and Processes and the attached table

Disinfection 0
Method - Chemical disinfection Dosage Point of application
0 0 0

Is there standby disinfection equipment? 0

...in good working order? 0 Is there emergency power to the disinfection equipment? 0
If not, are critical spare parts on hand or available? 0
Have there been any interruptions in disinfection in the past yea 0 Is the facility subject to flooding? 0
If yes, describe 0
Where does the PWS measure disinfection residual for compliance with the SWTR requirement that it be >= 0.2 mg/L at POE? 0
How is it measured? 0 Equipment manufacturer & model number 0
Free chlorine residual at POE as ,measured by PWS during survey 0 Disinfection residual detectable at end of distribution system? 0
Free chlorine residual at POE as measured by surveyor during survey 0 Comments 0
 PWS NAME
DATE
PWSID #

Method - UV disinfection Point of application UV Manufacturer and model number

0 0
Is there: A monitor / alarm for flow rate? 0 UV sensor to measure irradiance? 0 UV status alarm? 0
What is the UV dose (mj/sq cm) 0 How often is the unit cleaned and the bulb changed 0
Are spare bulds on hand? 0
Disinfection Profiling (Nontransient Systems)
Did they receive an exemption from profiling from EPA? 0
If not exempted, did profiling start on or before 7/1/2003 (systems serving <10,000 but >500) or 1/1/2004 (smaller systems)? 0
If not, indicate when profiling started 0
Skim the disinfection profile (graphic, spreadsheet etc.) to ensure that weekly log inactivation calculations are being made.
Note the lowest monthly avg. log Giardia inactivation obvserved from the profile: Month 0 Lowest mo. avg. log Giardia inactivation 0
This value should not be less than the logs inactivation**needed per the CT Calculation below.
Did the PWS make a significant change (new disinfectant, new location, etc.) to disinfection practices after 7/1/2004 ? 0
Date of the change 0 Was EPA consulted before making the change? 0
Describe the change 0
0
Stage 1 DBPR Monitoring Plan (Nontransient Systems)
Is there a plan available at the PWS for monitoring DBPs and disinfectant residuals per regs? 0
If using conventional filtration:
Is there a plan available at the PWS for monitoring DBP precursors? 0 Is it up to date and reflecting the current distribution system? 0
What types of Maximum Residual Disinfectant Levels (MRDLs) are being measured? 0
If using conventional filtration as the final filter barrier:
How does the PWS comply with the DBP precursor removal requirements? 0

Compliance with the SWTR 3-log Giardia and 4-log virus reduction requirements Must be achieved before or at first customer or user. Note: Compliance with Crypto 2-log
removal requirements determined by meeting monthlt IESWTR/LTIESWTR turbidity requirements.
Final filtration barrier 0
Logs removal credited for that barrier : ** logs inactivation needed :
for Giardia = 0.00 for Giardia = 0.00
for viruses = 0.00 for viruses = 0.00
Treatment Technique Inactivation Determination
1. If the PWS does their own daily or weekly CT inactivation calculation, verify the accuracy of those calculations. If accurate, indicate the lowest total logs Giardia
and virus inactivation calculated during the past year for all segments where CT credit is used:
Total logs Giardia inactivation from all segments 0.00
Total logs viurs inactivation from all segments 0.00
Are Giardia and virus total treatment requirements ** met? 0
 PWS NAME
DATE
PWSID #

OR
2. Do a conservative calculation
for each inactivation segment where credit is desired for Giardia and virus inactivation:
Segment #1 Segment #2 Segment #3
Disinfectant 0 0 0
Lowest disinfectant residual, mg/L 0 0 0
and where measured 0 0 0
Water pH (highest) 0 0 0
Water Temperature (lowest), centigrade 0 0 0
Maxumum hourly flow rate, gpm 0 0 0
Vessel 0 0 0
Volume, gallons 0 0 0
Baffle factor 0 0 0
Logs Giardia inactivation 0.00 0.00 0.00
Logs virus inactivation 0.00 0.00 0.00
Total for all segments:
Logs Giardia inactivation 0.00
Logs virus inactivation 0.00
Are Giardia and virus total treatment requirements ** met? 0

Fluoridation? 0
Is system adjusting the natural fluoride level? 0 If yes, answer the following questions. Are fluoride analysis results recorded daily? 0
What chemicals are used? 0
Analysis results are reported to: 0 Does system participate in monthly split sampling? 0
Has a trained operator been designated responsible for each fluoridation system?Fluoride feed pump inter-
(trained = 6 hours of fluoridation training) 0 locked to: 0
Fluoride feed pump has secondary flow control via a:
0 Fluoride injection system has anti-siphon protection at: 0
If fluorosilicic acid is being used: Acid is being injected at full strength (23-25%) 0 Are scales used to track daily total
Is maximum 7 day supply of acid connected to suction side of chemical feed pump? 0 total weight of acid injected? 0
Comments 0
 PWS NAME
DATE
PWSID #

TREATMENT OBJECTIVES & PROCESSES

Describe the drinking water treatment processes -- use a separate description for each facility or situation (e.g., if groundwater is treated by different processes than is surface water,
describe both the SW treatment plant and the GW treatment plant). Use the treatment codes from the attached list, preferably listed in the order that the water flows through them.

Example:
Facility Treatment Objective
Surface Water Treatment Plant Particulate Removal
" " Corrosion Control
Facility Treatment Objective
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Treatment Process Code
Coagulation P240
Inhibitor, Polyphosphate C447
Treatment Process Code
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

Comments: 0

DATE
The first letter of each code is
the objective of the treatment:
B = Disinfection By-products Control
C = Corrosion Control
D = Disinfection
E = Dechlorination
F = Iron Removal
I = Inorganics Removal
M = Manganese Removal
O = Organics Removal
P = Particulate Removal
R = Radionuclides Removal
S = Softening (hardness removal)
T = Taste/Odor Control
Z = Other
CODE - PROCESS
B121 - Activated Carbon, Granular
B125 - Activated Carbon, Powdered
B141 - Aeration, Cascade
B143 - Aeration, Diffused
B145 - Aeration, Packed Tower
B147 - Aeration, Slat Tray
B149 - Aeration, Spray
B160 - Algae Control
B200 - Chloramines
B220 - Chlorine Dioxide
B240 - Coagulation
B344 - Filtration, Pressure Sand
B345 - Filtration, Rapid Sand
B360 - Flocculation
B500 - Lime - Soda Ash Addition
B541 - Ozonation, Post
B543 - Ozonation, Pre
B600 - Rapid Mix
B640 - Reverse Osmosis
B660 - Sedimentation
B720 - Ultraviolet Radiation
B741 - pH Adjustment, Post
B742 - pH Adjustment, Pre
C441 - Inhibitor, Bimetallic Phosphate
C443 - Inhibitor, Hexametaphosphate
C445 - Inhibitor, Orthophosphate
C447 - Inhibitor, Polyphosphate
C449 - Inhibitor, Silicate
C680 - Sequestration
C740 - pH Adjustment
C741 - pH Adjustment, Post
D200 - Chloramines
D220 - Chlorine Dioxide
D346 - Filtration, Slow Sand
D401 - Gaseous Chlorination, Post
D403 - Gaseous Chlorination, Pre
D421 - Hypochlorination, Post
D423 - Hypochlorination, Pre
D541 - Ozonation, Post
D543 - Ozonation, Pre
D720 - Ultraviolet Radiation
E121 - Activated Carbon, Granular
E141 - Aeration, Cascade
E143 - Aeration, Diffused
E145 - Aeration, Packed Tower
E147 - Aeration, Slat Tray
E149 - Aeration, Spray
E620 - Reducing Agents
E623 - Reducing Agents, Sodium Bisulfate
E625 - Reducing Agent, Sodium Sulfite
E627 - Reducing Agent, Sulfur Dioxide
F141 - Aeration, Cascade
F143 - Aeration, Diffused
F145 - Aeration, Packed Tower
F147 - Aeration, Slat Tray
F149 - Aeration, Spray
F300 - Distillation
F343 - Filtration, Greensand
F344 - Filtration, Pressure Sand
F345 - Filtration, Rapid Sand
F403 - Gaseous Chlorination, Pre
F423 - Hypochlorination, Pre
F543 - Ozonation, Pre
F560 - Permanganate
F580 - Peroxide
F640 - Reverse Osmosis
F660 - Sedimentation
F680 - Sequestration
F700 - Sludge Treatment
F740 - pH Adjustment
F742 - pH Adjustment, Pre
I100 - Activated Alumina
I121 - Activated Carbon, Granular
I180 - Bone Char
I240 - Coagulation
I300 - Distillation
I320 - Electrodialysis
I344 - Filtration, Pressure Sand
I345 - Filtration, Rapid Sand
I360 - Flocculation
I460 - Ion Exchange
I500 - Lime - Soda Ash Addition
PWS NAME
PWSID #
I600 - Rapid Mix R100 - Activated Alumina
I640 - Reverse Osmosis R121 - Activated Carbon, Granular
I660 - Sedimentation R141 - Aeration, Cascade
I680 - Sequestration R143 - Aeration, Diffused
I700 - Sludge Treatment R145 - Aeration, Packed Tower
I742 - pH Adjustment, Pre R147 - Aeration, Slat Tray
M300 - Distillation R149 - Aeration, Spray
M343 - Filtration, Greensand R180 - Bone Char
M403 - Gaseous Chlorination, Pre R240 - Coagulation
M423 - Hypochlorination, Pre R300 - Distillation
M543 - Ozonation, Pre R320 - Electrodialysis
M640 - Reverse Osmosis R344 - Filtration, Pressure Sand
M680 - Sequestration R345 - Filtration, Rapid Sand
N000 - No Treatment/Not Applicable R360 - Flocculation
N997 - Treatment Applied at Plant R460 - Ion Exchange
N998 - Treatment Applied at Point of Entry R500 - Lime-Soda Ash Addition
O121 - Activated Carbon, Granular R600 - Rapid Mix
O125 - Activated Carbon, Powdered R640 - Reverse Osmosis
O141 - Aeration, Cascade R660 - Sedimentation
O143 - Aeration, Diffused R680 - Sequestration
O145 - Aeration, Packed Tower R700 - Sludge Treatment
O147 - Aeration, Slat Tray R742 - pH Adjustment, Pre
O149 - Aeration, Spray S240 - Coagulation
O160 - Algae Control S300 - Distillation
O240 - Coagulation S344 - Filtration, Pressure Sand
O300 - Distillation S345 - Filtration, Rapid Sand
O345 - Filtration, Rapid Sand S360 - Flocculation
O360 - Flocculation S460 - Ion Exchange
O403 - Gaseous Chlorination, Pre S500 - Lime-Soda Ash Addition
O423 - Hypochlorination, Pre S600 - Rapid Mix
O543 - Ozonation, Pre S640 - Reverse Osmosis
O560 - Permanganate S660 - Sedimentation
O580 - Peroxide S680 - Sequestration
O620 - Reducing Agents S700 - Sludge Treatment
O640 - Reverse Osmosis S742 - pH Adjustment, Pre
O660 - Sedimentation T121 - Activated Carbon, Granular
O742 - pH Adjustment, Pre T125 - Activated Carbon, Powdered
P240 - Coagulation T141 - Aeration, Cascade
P300 - Distillation T143 - Aeration, Diffused
P341 - Filtration, Cartridge T145 - Aeration, Packed Tower
P342 - Filtration, Diatomaceous Earth T147 - Aeration, Slat Tray
P344 - Filtration, Pressure Sand T149 - Aeration, Spray
P345 - Filtration, Rapid Sand T160 - Algae Control
P346 - Filtration, Slow Sand T403 - Gaseous Chlorination, Pre
P347 - Filtration, Ultrafiltration T423 - Hypochlorination, Pre
P360 - Flocculation T543 - Ozonation, Pre
P520 - Microscreening T560 - Permanganate
P600 - Rapid Mix T580 - Peroxide
P660 - Sedimentation P348 - Filtered
P700 Sludge Treatment P349 - Unfiltered -- Successfully Avoiding
P742 - pH Adjustment, Pre N350 - Unfiltered, but Required to Filter
 PWS NAME
DATE
PWSID #

TRANSMISSION DATA, TREATED WATER

Service area or designation 0 Date in service 0
Point of origin 0 Point of termination 0 Length 0
Diameter 0 Material 0 Pres range 0 Flow rate (gpm) 0
Controls and/or PRVs (describe) 0 ARVs 0 Condition 0
Any breaks in the last 2 years? 0 Is pump station subject to flooding? 0
If yes, describe 0

Pumps
Pump Name / Number Type / Material Standby Flow Rate Condition
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
Comments 0
STORAGE DATA, TREATED WATER
CLEARWELL SIZE (gallons) 0
TANKS AND CISTERNS Copy this page as needed for additional tanks.

Tank Name and/or # 0 0 0 0 0

Location: Latitude 0 0 0 0 0
Longitude 0 0 0 0 0

Style and Material 0 0 0 0 0

Capacity (gal.) 0 0 0 0 0
Total days of supply 0 0 0 0 0
Date(s) in service 0 0 0 0 0

Subject to flooding? 0 0 0 0 0
Structurally sound? 0 0 0 0 0
Well-maintained? 0 0 0 0 0
Overflow lines:
Turned downward? 0 0 0 0 0
Covered or screened? 0 0 0 0 0
3 diam. above ground? 0 0 0 0 0
Air Vents
Turned down? 0 0 0 0 0
Covered or screened? 0 0 0 0 0
 PWS NAME
DATE
PWSID #

TANKS AND CISTERNS, cont'd

Drain & Cleanout lines
Turned down? 0 0 0 0 0
Covered or screened? 0 0 0 0 0
3 diam. above ground? 0 0 0 0 0
Can tank be isolated? 0 0 0 0 0
Storage
Covered/enclosed? 0 0 0 0 0
Safety Measures
Tank last cleaned? 0 0 0 0 0
Disinfected after repair? 0 0 0 0 0
Community served 0 0 0 0 0

Comments 0

DISTRIBUTION DATA
Lines Origin Material Inside Diameter Length
Main Lines 0 0 0 0
0 0 0 0
Dist Lines 0 0 0 0
0 0 0 0
Svc Lines 0 0 0 0
0 0 0 0
Does this PWS have any asbestos pipe in its distribution? 0 Is there sufficient earth cover to protect the mains from frost damage/heavy loads? 0
Are materials of mains designed and selected to resist Has the PWS had problems due to this? 0
corrosion, electrolysis, and deterioration? 0 If this PWS serves any stock-watering tanks, is there backflow prevention? 0
Is there a plan for future installation & testing of backflow Dead Ends: 0 How Many? 0
prevention devices in vulnerable portions of the distrib system? 0 Is there a program to eliminate these dead ends where feasible? 0
Is there a flushing schedule? 0 Is the system looped? 0
Comments 0

Pressure zones Control

Area Pressure Range Auto Manual Remote
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
Is there adequate pressure (at least 20 psi) in the distribution system under all conditions of flow? 0
Comments 0

Cross Connection Control

Location Type Size Last Tested
0 0 0 0
0 0 0 0
0 0 0 0
Date of cross connection control training for operator 0
Is there interconnection with any other system? 0 Describe 0
Comments 0
 PWS NAME
DATE
PWSID #

GENERAL MAINTENANCE
Is there an adequate maintenance program? 0 Describe 0
0 0
Are gate valves exercised? 0 Are as-builts updated? 0
How often is system flushed? 0 Is there a written program or schedule for routine preventive maintenance for the entire
Is there a formal plan for routine inspection and maintenance of pumps & motor 0 facility and exercising critical valves/fire hydrants? 0
Conduct by PWS personnel or qualified pump contractor? 0 If yes,describe 0
Is there a log of all breaks and extent of repairs? 0 0
Is there a system for assuring inventory of essential spare parts and back-up equipment? 0
If yes,describe 0
Is PWS in contact with contractors and vendors to assure prompt priority service? 0
Comments 0

SAFETY AND SECURITY DATA

Is there a safety prog. on measures to be taken if someone is injured? 0 If yes, attach copy.
Are there written operating procedures for routine and emergency system operations? 0 If yes, attach copy.
Security How Often How Often
Fenced Locked Patrolled Fenced Locked Patrolled
Wells 0 0 0 Pump Houses 0 0 0
Storage Shed for Chemicals 0 0 0
Springs & Infiltration Galleries 0 0 0 Treatment Plants 0 0 0
Stream intakes 0 0 0 Storage Tanks 0 0 0
Reservoirs/Lakes 0 0 0 Manholes & Vaults 0 0 0
Is access to all facilities restricted to authorized personnel? 0
Comments 0

Confined Spaces
Is there a confined spaces policy? 0 Has there been training? 0 Is adequate equipment available? 0
Is operator fully aware of OSHA confined spaces regulations? 0
Comments 0
Chlorine Safety 0
Is there ongoing chlorine safety training for all water system personnel? 0
Describe 0
Comments
Are chlorine room doors ...
posted with warnings? 0 0
do they open outward? 0 0
do they open to the exterior of the building? 0 0
all equipped with crash bars and viewports? 0 0
Is there a leak detector in the chlorine room with an audible alarm? 0 0
Are chlorine feed and storage areas isolated from other facilities? 0 0
 PWS NAME
DATE
PWSID #

Chlorine Safety cont.

Are chlorine areas adequately ventilated? 0 0
Are all chlorine cylinders adequately restrained? 0 0
Are self-contained breathing units...
readily available for use in chlorine emergencies? 0 0
where are they stored? 0
Are water system personnel adequately trained in the use and maintenance of
the self-contained breathing apparatus? 0 0
Are chlorine leak kits available? 0 0
Are all personnel trained in proper use of chlorine leak kits? 0 0
Comments 0

Chemical Safety 0
Comments
Do operators understand the risks and safety measures involved in handling chemicals? 0 0
Are all treatment chemicals and maintenance supplies properly stored? 0 0
Are oxidizers, corrosives, and flammables stored in separate areas and
in closed, marked containers? 0 0
Are flammables appropriately stored, away from combustion sources? 0 0
Are areas where solvents, aerosols and chemicals are used adequately ventilated? 0 0
Are adequate masks, protective clothing & safety equipment provided & required? 0 0
Are all personnel trained in proper handling of all utilized chemicals and materials? 0 0
Are they familiar with the MSDS sheets 0 0
Are bulk storage areas physically isolated from treatment areas to prevent spills
from entering treated or untreated water? 0 0
Is the fire department familiar with the facilities and their contents? 0 0
Comments 0
EMERGENCY RESPONSE
Is there an emergency power source... for the source? 0 for transmission system (raw water)? 0
for the disinfection equipment? 0 for transmission sys (treated water)? 0 for distribution system? 0
If there is an emerg. power, is source a generator or local elec. supplier? 0 Is emergency power source sufficient to supply 100%
Is emergency power exercised routinely under load conditions, for at least 30 mins at a time? 0 of the avg. daily demand of the system?
Has the local electric utility been made aware of any generator(s)? 0
Describe emergency response plan(s), including any procedures for handling ruptures, chemical overfeeds or acts of terrorism.
0
Is there a plan in place to provide temporary water in the event of an emergency? 0 If yes, when was plan last updated? ###
Describe 0
Comments 0
 PWS NAME
DATE
PWSID #

MONITORING AND RECORDS

Number of bacteria samples per month req 0 Sample siting plan submitted to EPA? 0 Are copies of monitoring results, sys. records & plans...
Is sampling procedure adequate? 0 retained on the premises? 0 0
Does operator know what to do in the event of MCL exceedance or TC+ report? 0 current? 0
Are extra bottles available in the event of repeat sampling for coliform? 0 available to the surveyor? 0
Are there records and data manage. sys. for sys. O&M data, for regulatory compliance and for sys. management and admin? 0
Describe 0
Any reports of waterborne disease? 0
If yes, give dates and describe each report of bacteriology violations (w/in last 2 yrs.)
Date Type(s) Agency action System response
0 0 0 0
0 0 0 0
0 0 0 0

Comments 0

Samples Taken During Survey

Type Results Are appropriate
0 0.00 test kits and reagents
0 0.00 available for daily monitoring? 0
What certified lab(s) does sample testing? 0

Next tests due.. Asbestos* Nitrate IOCs VOCs SOCs Disinfection Byproducts* Lead and Copper* Radionuclides

Comments

*Sample in the distribution system

NOTE: All chemicals except those marked with an "*" should be sampled at the entry point to the distribution system after treatment.

Attach to this report any available system maps or diagrams.

APPENDIX

C/T Calculation spread sheet