Check if Issues Found. Check if Reviewed. Assessment Elements

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1 Oklahoma Department of Environmental Quality Water Quality Division, Public Water Supply Group Revised Total Coliform Rule Level 2 Assessment Form RTCR-2 PWS ID#: PWS Name: County: City/Town: Seasonal System: System Type: C NTNC NC Yes No Primary Operator (print name): Phone: Person who collected TC samples, if different from Primary Operator: Phone: Section A Review Elements of the PWS Instructions: The Level 2 Assessment must be completed by DEQ personnel or by a party approved by DEQ. The assessment shall be completed based on an on-site inspection and available data and documents, as follows. a) Review and evaluate each of the listed elements typically found in a PWS. Mark (χ) for each element that was reviewed. b) Mark (χ) if any potential causes of contamination were identified with that element. c) Describe any issues identified and provide all requested information in the column. Explain any elements that were not reviewed. Indicate element number in the description. d) Describe any recommended or required corrective actions in the column. Indicate element number of corrective action. 1.0 Sampling 1.1 Are there any issues with the location and condition of the tap? Describe the location and condition. 1.2 Are there any issues with the use of the connection/tap, or is the connection/tap used infrequently? Describe the regular use of the connection/tap. 1.3 Were there any plumbing breaks, construction, or other maintenance in the vicinity of sample site? 1.4 Are there any identified cross connections after the service connection or in the plumbing of the premises? Describe if present. 1.5 Were any backflow prevention devices at the sample location not operational or not maintained? 1.6 Were there any low pressure events or changes in water pressure after the service connection or in the plumbing at the premises? If yes, when?

2 1.7 Was there hot water intrusion at the sample site? 1.8 Are there any issues with treatment devices (point of entry and/or point of use)? Describe any treatment devices after the service connection or in the premises of the sample site (e.g. reverse osmosis system, water softener, etc.). 1.9 Have there been any plumbing changes or other construction within the premises? If yes, when and what was the repair or change? 1.10 Are there other changes in conditions at the sample site? 1.11 Does the tap have threads on the inside of the spout? 1.12 Was an unsuitable sample tap used? (e.g. frostfree hydrant, below ground level, tap points upward, etc.) 1.13 Was an unsuitable faucet used as a sample tap? (e.g. swivel-type faucet, auto-sensing faucet, ball joint faucet, etc.) 1.14 Was there inadequate flushing of the tap before sampling? 1.15 Was the aerator not removed before sampling? 1.16 Was the sample tap not disinfected before sampling? 1.17 Was the chlorine residual at the sample tap inadequate (i.e. less than 0.2 ppm free chlorine residual or less than 1.0 ppm total chlorine residual)? 1.18 Record the chlorine residual at the sample tap. Cl2 Res.: ppm 1.19 Were there visibly unsanitary conditions at the sampling site and/or sample tap? 1.20 Does the tap have leaky packing material around the stem? 1.21 Other issues with the sampling site and/or sample tap? 2.0 Distribution System 2.1 Is there evidence that the system experienced low or negative pressure prior to sampling? If yes, describe event and when it occurred.

3 2.2 Have there been any water main breaks? If yes, when? 2.3 Are there any cross connections? List and describe all existing cross connections. 2.4 Are there any sanitary defects in the pump station? 2.5 Were the pumps operated improperly? 2.6 Was there a failure in the pump(s)? 2.7 Last pump maintenance/service date Date: 2.8 Has there been a loss of power within the distribution system? 2.9 Has there been any improper operation of the valves? 2.10 Has any operation of the valves resulted in breakage? 2.11 Has there been a valve failure? 2.12 Has there been any improper operation of airrelief or air-vacuum valves? 2.13 Have there been any operational changes within the distribution system? 2.14 Have water leaks been discovered within the distribution system? 2.15 Has the distribution system had inadequate disinfectant residuals (i.e. less than 0.2 ppm free chlorine residual or less than 1.0 ppm total chlorine residual)? 2.16 Record the lowest chlorine residual found in the distribution system Is there improper surge control? 2.18 Are there any sheared or improperly used hydrants? 2.19 Are any buildings (e.g. valve vaults, pumping facilities, etc.) kept in visibly unsanitary conditions? 2.20 Is the valve vault subject to flooding, or does the vent terminate below grade? 2.21 Are any hydrants or blow offs located in an area with a high water table or in pits? 2.22 Is the distribution system unsecured, allowing unauthorized access? Cl2 Res.: ppm

4 2.23 Are there any high risk sites without operational and maintained backflow prevention devices? 2.24 Have there been any water main repairs or additions? If yes when, and what was the repair or addition? 2.25 Have any other maintenance activities recently been conducted in the distribution system? 2.26 Are there places in the distribution system where it is difficult to maintain a chlorine residual without flushing? 2.27 Was there any scheduled flushing of the distribution system? If yes, when? 2.28 Is there any evidence of intentional contamination in the distribution system? 2.29 Other issues with the distribution system? 3.0 Storage Facilities 3.1 Do the overflow and vents have missing or damaged screens? 3.2 Is the facility unsecured, allowing unauthorized access? 3.3 Does the hatch have an improper gasket and/or missing or damaged seal? 3.4 Does the drain/overflow line have an inadequate air gap (i.e. less than 12 )? 3.5 Is the vent installed improperly? 3.6 Were there any observed leaks? 3.7 Are there any unsealed openings in the storage facility, such as access doors, vents, or joints? 3.8 Is there any observed physical deterioration of the tank? Could the physical condition of the tank be a source of contamination? 3.9 Are there observable issues with the structure of the tank s foundation, roof, or walls? 3.10 Are there any issues with ladders or catwalks that could result in contaminants falling into finished water? 3.11 If present, is the pressure tank providing less than the required minimum pressure?

5 3.12 Have there been operational changes at the water storage facility? 3.13 Has there been any recent facility maintenance (i.e. painting/coating)? If yes, when? 3.14 Are there any issues with tank configuration? Describe the tank configuration. (e.g., the tank "floats" on the distribution system or has separate inlet and outlet lines, etc.) 3.15 Is there inadequate chlorine residual in water exiting the storage tank (i.e. less than 0.2 ppm free chlorine residual or less than 1.0 ppm total chlorine residual)? 3.16 Record the measured chlorine residual (total/free) of water exiting the tank Have the level control valves, altitude valves, and related appurtenances been operated improperly? Cl2 Res.: ppm 3.18 Is there any evidence of intentional contamination at the storage tank? 3.19 Are there any potential sources of contamination near the storage tank? 3.20 Does the tank need cleaning? 3.21 Date the tank was last inspected Date: 3.22 Date the tank was last cleaned Date: 3.23 Are there visibly unsanitary conditions at the storage tank? 3.24 Other issues with the water system s storage? 4.0 Treatment Process (if applicable) 4.1 Were there any interruptions in treatment (e.g. lapses in chemical feed, turbidity excursions, disinfection, etc.)? If yes, provide details for which part, when, and for how long. 4.2 Are any treatment devices inoperable or not well maintained? 4.3 Has there been any recent installation or repair of treatment equipment or other maintenance activity?

6 4.4 Were there any recent changes in the treatment process (e.g. addition of a process, change in chemical or dosage, etc.)? If yes, provide details for the change and when it occurred. 4.5 Was disinfection inadequate at the point of entry? (i.e. less than 1.0 ppm free chlorine residual or less than 2.0 ppm total chlorine residual) 4.6 Record the POE chlorine residual. 4.7 Did a review of the filter turbidity profiles reveal any anomalies? 4.8 Were there any finished turbidity measurements above 0.3 NTU? 4.9 Were there any failures to meet the C x T calculations? 4.10 Were the flow rates above the design capacity? 4.11 Were there any anomalies of the settled water turbidities? 4.12 Has there been a loss in power at the treatment plant? 4.13 Have there been any operational changes at the treatment plant? 4.14 Other issues with the treatment system? 5.0 Sources - General Cl2 Res.: ppm 5.1 Has the water system recently activated any new water sources? 5.2 Has the water system switched between its typical water sources recently? 5.3 Has the water system begun using any atypical water sources (e.g. auxiliary system, consecutive connective, emergency source, etc.)? 5.4 Any other general issues with the sources? 6.0 Sources Well(s) 6.1 Is the sanitary seal missing or damaged? 6.2 Is the well cap vent/vent screen missing or damaged? 6.3 Is the vent or pump to waste missing an approved air gap? 6.4 Are there any cross connections at the wellhead?

7 6.5 How is the well used? ( applicable) Primary Backup Emergency Not a PWS well Not a drinking water well 6.6 Is the well casing an inadequate height above grade? Record how far the casing extends above grade. Height: in 6.7 Is there evidence of standing water near the wellhead? 6.8 Is the wellhead unsecured, allowing unauthorized access? 6.9 Have there been any sewer spills, source water spills, or other potential sources of contamination within 300 feet of the well? 6.10 Has there been heavy rainfall or flooding near the well? 6.11 Is there a missing or damaged grout seal? 6.12 Is there an unprotected opening in the pump/pump assembly? 6.13 Is there a damaged pitless adapter? 6.14 Have there been operational changes at the well? 6.15 Is the well pad damaged/inadequate? 6.16 Have there been changes in the static/pumping levels? 6.17 Has there been a new well added to the water system? 6.18 Has the water system recently switched to a different well? 6.19 Has there been recent maintenance activity at the well? 6.20 Are there visibly unsanitary conditions at the well? 6.21 Other issues with the water well(s)? 7.0 Sources - Surface Water Supply 7.1 Have there been any sewer spills or other potential sources of contamination within 300 feet of the water body? 7.2 Have there been any algal blooms? 7.3 Has source water turnover occurred?

8 7.4 Has the water system recently switched to a different intake? 7.5 Have there been recent changes in the water table or reservoir capacity? 7.6 Has a new surface water source recently been added to the water system? 7.7 Have there been operational changes at the source? 7.8 Have there been high turbidity measurements in the raw water source? 7.9 Has there been any heavy rainfall or flooding at the water body? 7.10 Has there been recent maintenance activity at the source? 7.11 Other issues with the surface water source(s)? 8.0 Sources Spring(s) 8.1 Is the spring improperly developed? 8.2 Is the spring box in poor condition? 8.3 Is the spring unsecured, allowing unauthorized access? 8.4 Is there a potential source of contamination within 300 feet of the spring? 8.5 Have there been changes in the water table or in spring production? 8.6 Have there been operational changes at the spring? 8.7 Has there been heavy rainfall or flooding at the spring? 8.8 Has there been recent maintenance activity at the spring? 8.9 Are there visibly unsanitary conditions at the spring? 8.10 Has the water system recently switched to a different spring? 8.11 Has a new spring been added to the water system? 8.12 Other issues with the spring(s)?

9 9.0 General 9.1 Has there been heavy rainfall / flooding / snow / ice storm, etc.? 9.2 Has there been a recent fire-fighting event or other unusual water use? 9.3 Have there been any extremes in heat or cold? 9.4 Have there been any interruptions to the electrical power? 9.5 Is the area served by the water system experiencing a drought? 9.6 Are there signs of vandalism or forced entry at any water system assets? 9.7 Has the water system been dormant (i.e. not serving water) for more than 60 days? 9.8 Have there been any additional samples recently collected, including source water samples, with TC+ or E. coli positive sample results? This includes line tests and compliance samples. 9.9 Is there a past history of TC+ or E. coli positive sample results, including distribution system and source water samples? This includes line tests and compliance samples Has the water system received any RTCR or GWR monitoring violations in the last 12 months? 9.11 Have there been any reports of community illness or an outbreak that could be waterborne? 9.12 Most recent date on which safe total coliform samples were collected Date: 9.13 Are there any other issues with records or maintenance at the water system? 9.14 If the water system is a seasonal system, were there any issues during the most recent start-up procedure?

10 9.15 Were there any operations or maintenance activities conducted that could have introduced total coliform / E. coli? 9.16 Are there any historical issues from previous inspections that have not been fixed? 9.17 Other general issues with the water system? Section B Additional Information Instructions: Use this space to provide additional information that supports your findings (e.g. water quality and pressure monitoring data). Include corresponding dates with your findings. Section C Required Corrective Actions Instructions: Use this space to describe any required corrective actions that have been taken or are required to be taken. Include a schedule for completion of required corrective actions and the dates of corrective actions that have already been completed

11 Section D Recommended Corrective Actions Instructions: Use this space to describe any recommended corrective actions that have been taken or are recommended to be taken. Include a schedule for completion of recommended corrective actions. Section E Personnel Completing This RTCR Level 2 Assessment I certify that the information contained herein is a true, accurate, and complete reflection of the Level 2 Assessment to the best of my knowledge and belief. Print Name: Title: License No.: Signature: Date: Phone No.: DEQ USE ONLY Has assessment been successfully completed? Yes / No Comments: Has likely reason for EC+ occurrence been found? Yes / No Comments: Has PWS corrected the problem? Yes / No Comments: Date Received: DEQ Reviewer: Date : Violations addressed by RTCR Level 2 Assessment: