Document cayugacounty_gov_doc_5d2af1e1cd

Public Water System Name Date Trigger Exceeded Date of Assessment Source Water Type(s)  Surface  Ground Public Water System ID # County Town, Village, or City  GWUDI  Purchase with chlorination NY  Purchase w/out chlorination Section A – System Evaluation Review and evaluate all of the elements listed - Identify any potential causes of contamination and check all that apply. Each section requires a response. Describe each issue and any corrective actions taken in detail, in sections B and C. 1. GENERAL Issue Identified: Yes  No  Have there been any recent interruptions and/or changes at relevant facilities prior to the collection of total coliform samples?  Treatment Process  Loss of Pressure  Operation & Maintenance  Vandalism  Unsanitary Conditions  Major Fire  Hydrant Flushing  Water Main Break/Repair  Low/No Residuals  Other (describe): 2. SAMPLE SITE and SAMPLE PROTOCOL Issue Identified: Yes  No  Was the sample protocol reviewed and followed?  Outside hose spigot was used to collect sample  Tap was not adequately flushed prior to sample collection  The aerator on the faucet was not removed prior to collection  Sample bottle used to collect sample had a broken seal  Auto sensing/ swivel type faucet used for sample collection  Change in condition or location of tap  Other (describe): 3. DISTRIBUTION SYSTEM Issue Identified: Yes  No  Were any of these events observed prior to the collection of total coliform samples?  Unexpected reduction in pressure (<20 psi)  Identified cross connection  Faulty backflow prevention device  Improper operation of air-relief/ air-vacuum valves  Improper operation of a pump station  Other (describe): 4. STORAGE TANK(S) Issue Identified: Yes  No   Overflow pipe screen missing/improper size  Vent screen missing/improper size  Security breach at tank  Access hatch left open  Sanitary condition of tank  Structural condition of tank  Other (describe): 5. TREATMENT PROCESS Issue Identified: Yes  No   Chlorinator malfunction  Low/no chlorine residual  Unmaintained filters  Interruption in treatment/disinfection (i.e. power loss)  Operation & Maintenance procedures not followed  Point of Entry/Point of Use treatment issue  Softener issue  Other (describe): 6. SOURCE Issue Identified: Yes  No  This includes Well, Spring, or Surface Water.  Well cap missing/damaged  Sanitary seal damaged or not present  Condition of spring box unsanitary  Source subject to heavy rains/ flooding, preceding positive total coliform sample collection  Damaged/ unscreened vent  Security breach at source  Absent air gap (if required)  Cross connection identified  Other (describe): NEW YORK STATE DEPARTMENT OF HEALTH Revised Total Coliform Rule Bureau of Water Supply Protection Level 1 Assessment Form DOH-5197 (8/15) Page 1 of 2 ---PAGE BREAK--- Section B –Issue Description In this section, use the space provided to describe the event and provide additional information on potential causes of contamination identified during the assessment. Include corresponding dates whenever possible. If more space is needed attach additional sheets of paper.  Check this box if there were no known causes for this contamination. Section C – Corrective action taken or to be taken In this section, describe corrective actions (completed or proposed), and any measures the public water system plans to implement prior to the completion of any corrective actions, including specific dates. If more space is needed attach additional sheets of paper. Certification Please fill in the information below after completing this form. DOH-5197 (8/15) Page 2 of 2 Directions: 1. Completely fill in the public water system information in the first section of the form, including: Public Water System Name, Public Water System ID Date Trigger Exceeded, Date of Assessment, County, Town, Village/City, Source Water Type(s) 2. This form must be completed based on data and documents available to the Public Water System and maintained on file for a minimum of five years. 3. Complete all sections (A – C) and check each item that applies. If no issue was identified, check the appropriate box. 4. Sign and date the form. 5. This form must be submitted to the State (Local Health Department) within 30 days of triggering a Level 1 Assessment 6. If you have questions regarding the completion or content of this form, please contact your Local Health Department. Print name: Date: Signature: Reserved for State (or Local Health Department) Use Only Yes  No  Yes  No  Yes  No  1. Assessment has been successfully completed. 2. Likely reason for the total coliform positives is identified. 3. System has corrected the problem. 4. Name of State (Local Health Department) Reviewer Additional Notes