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DOH-5212 (3/16) p 1 of 6 Public Water System Name Date Trigger Exceeded Date of Assessment Source Water Type(s) Surface Ground GWUDI Purchase with chlorination Purchase w/out chlorination Public Water System ID # County Town, Village, or City NY 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 If any answers are marked “Yes” in questions a. through h. of this section, provide comments in Section B. Have any of the following occurred prior to collection of TC samples at related facilities within the PWS? a. Were there any recent operation and/or maintenance activities that could have introduced total coliforms? Yes No b. Has there been any vandalism and/ or unauthorized access to facilities? Yes No c. Are there any visible indicators of unsanitary conditions observed? Yes No d. Has there been any recent community illness suspected of being waterborne local public health official has confirmed that an outbreak occurred.) Yes No e. Did the water system receive any total coliform monitoring violations in the past 12 months? If yes, when? (Provide comments in Section B) Yes No f. Has there been any recent heavy rainfall? Yes No g. Has there been any recent rapid snow melt or flooding? Yes No h. Has there been any recent extremes in heat or cold? Yes No i. What was the most recent date on which satisfactory total coliform samples were taken? Date: Other comments on records and maintenance. NEW YORK STATE DEPARMENT OF HEALTH Bureau of Water Supply Protection Revised Total Coliform Rule Level 2 Assessment Form ---PAGE BREAK--- DOH-5212 (3/16) p 2 of 6 2. SAMPLE SITE and SAMPLE PROTOCOL If any answers are marked “Yes” for questions a. through d. provide comments in Section B. If any answers are marked “No” for questions e. through g. provide comments in Section B. a. Have there been any plumbing changes or construction after the service connection or in the premise plumbing? If yes, when and what was the repair or change? Yes No b. Have there been any plumbing breaks or failures after the service connection or in the premise plumbing? If yes, when? Yes No c. Were there any low pressure events or changes in water pressure after the service connection or in the premise plumbing? If yes, when? Yes No d. Are there any treatment devices after the service connection or in premise? Yes No e. Have the sample site plan and sample protocols been followed and reviewed? Yes No f. Were all of the backflow prevention devices present, operational, and maintained? Yes No g. Were the appropriate sampling protocols used (Flush tap, remove aerator, no swivel, fresh sample bottles, and sample storage acceptable)? Yes No h. What is the overall condition of the tap? (Provide comments) i. What is the location of the tap? (Provide comments) j. What is the regular use of the tap? (Provide comments) k. List any identified cross connections after the service connection or in premise plumbing. (Provide comments) Other comments on records and maintenance. ---PAGE BREAK--- DOH-5212 (3/16) p 3 of 6 3. DISTRIBUTION SYSTEM If any answers are marked “Yes” for questions a. through k. provide comments in Section B. If any answers are marked “No” for questions l. through n. provide comments in Section B. a. System pressure: Is there evidence that the system experienced low or negative pressure in the area of the positive samples? If yes, when? Yes No b. Pump station (if applicable): Are there any sanitary defects in the pump station? Yes No c. Was there any scheduled flushing of the distribution system? If yes, when? Yes No d. Fire hydrant/blow off: Are any of these devices located in an area with a high water table or in pits? Yes No e. Has there been any fires in the area? Does the fire department use any nearby hydrants for practice? Has routine flushing been performed recently? Yes No Yes No Yes No f. Have there been any recent repairs or additions in the area of the positive samples? If yes, when, and what was the repair or addition? Yes No g. Have there been any recent water main breaks? If yes, when? Yes No h. Are there any known areas of leaks in the distribution system? If so, where? Yes No i. Are there sections of the distribution system with very low or no water use? (ex. vacant manufacturing areas) Yes No j. Vaults: Is the vault subject to flooding? Yes No k. Vaults: Does the air vent terminate below grade? Yes No l. Vaults: Is the air vent screened? Yes No m. Vaults: Is the vent downturned? Yes No n. Are the backflow prevention devices at nearby high risk sites present, operational and maintained? (If no, provide comments in Section Yes No o. Last pump (booster stations) maintenance/service date. Date: Other comments on the distribution system. ---PAGE BREAK--- DOH-5212 (3/16) p 4 of 6 4. STORAGE TANK(S) If any answers are marked “Yes” for questions a. through d. provide comments in Section B. If any answers are marked “No” for questions e. through h. provide comments in Section B. a. Has there been any recent facility maintenance? (i.e. painting/coating) If yes, when? Yes No b. Are there any unsealed openings in the storage facility such as access doors, vents or joints? Yes No c. Are there any observed leaks? Yes No d. Physical condition of the tank – Are there any observed holes in the tank that could allow contamination in? Yes No e. Is adequate O&M being performed per AWWA schedule? Yes No f. Are the overflow and vents properly screened? Yes No g. Is the vent properly screened and covered? Yes No h. Does the drain/overflow line terminate a minimum of 12” above the ground? Yes No i. What is the measured chlorine residual (total/free) of the water exiting the storage tank today? Residual: j. Does the tank have a combined inlet/outlet or are there separate inlet and outlet lines? Combined Separate Other comments on the storage tank(s). 5. TREATMENT PROCESS If any are marked “Yes” for questions a. through f. provide comments in Section B. a. Was there any recent installation or repair of treatment equipment? Yes No b. Were there any recent changes in the treatment process? If yes, when, and what was the change? Yes No c. Were there any interruptions of treatment (lapses in chemical feed, turbidity excursions, disinfection)? If yes which part, when and for how long? Yes No d. Did a review of the compliance turbidity readings reveal any anomalies? Yes No e. Were there any failures to meet the CT calculations? Yes No f. Were the flow rates above the rated capacity? Yes No g. Are treatment devices operational and maintained? (If no, provide comments in Section Yes No h. What is the free chlorine residual measured at the point where CT is calculated? Residual: Other comments on the treatment process. ---PAGE BREAK--- DOH-5212 (3/16) p 5 of 6 6. SOURCE General a. Have any inactive sources recently been introduced into the system emergency/auxiliary sources)? (If yes, provide comments in Section Yes No b. Have there been any new sources introduced into the system? (If yes, provide comments in Section Yes No Well If any questions are marked “Yes” in questions a. through c. provide comments in Section B. If any questions are marked “No” in questions d. through f. provide comments in Section B. a. Are there any unprotected cross connections at the wellhead(s)? Yes No b. Is there evidence of standing water near the wellhead(s)? Yes No c. Have there been any sewage spills, chemical spills or other disturbances near the well(s)? Yes No d. Is the casing in good condition with no evidences of breaks? Yes No e. Are well caps vented? Yes No f. Do all wells meet the construction standards in Appendix 5-B? Yes No Other comments on the well system. Spring a. What is the condition of the area surrounding the spring box? (Provide comments) b. What is the condition of the spring box (Used to collect flow from spring; should be water tight vermin-proof)? (Provide comments) c. Are overflow pipes screened? (If no, provide comments in Section Yes No Other comments on the spring system. Surface Water Supply If any are marked “Yes” in questions a. through c. provide comments in Section B. a. Have there been any sewage spills, chemical spills or other disturbances near the source? Yes No b. Has source water turnover occurred recently? Yes No c. Have there been any recent algal blooms near the intake? Yes No Other comments on the surface water supply. ---PAGE BREAK--- DOH-5212 (3/16) p 6 of 6 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 additional 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. Print name Date Signature Reserved for State (or Local Health Department) Use Only 1. Assessment has been successfully completed Yes No 2. Likely reason total coliform positives is identified Yes No 3. System has corrected the problem Yes No 4. Name of State (Local Health Department) Reviewer Additional Notes Directions 1. Completely fill in the public water supply information in the first section of the form, including: Public Water Supply Name, Public Water Supply 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 completed by the State (Local Health Department) within 30 days of a Public Water System triggering a Level 2 Assessment. 6. A completed copy of this form shall be given to the Public Water System.