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SMALL DRINKING WATER SYSTEM

Kentucky Peer Review Program – Self Evaluation

Water System Name _________________________________________________

Address ___________________________________________________________

County _______________________ ADD District _________________________

Phone ____________________________ Date ____________________________

WATER SYSTEM MANAGEMENT & OPERATIONS

1.

Do you have a compliance monitoring schedule posted?

□ Yes     □ No     □ Not Sure

2.

Are reporting requirements followed?

□ Yes     □ No     □ Not Sure

3.

Are records of the monitoring program adequately maintained?

□ Yes     □ No     □ Not Sure

4.

Are the water system testing facilities adequate?

□ Yes     □ No     □ Not Sure

5.

Is the water system analysis equipment adequate and calibrated?

□ Yes     □ No     □ Not Sure

6.

Is a certified lab used?

□ Yes     □ No     □ Not Sure

If “Yes” what is lab name? __________

7.

Have you had any violations in the past year?

8.   If you have had violations, have they

been corrected?

□ Yes     □ No     □ Not Sure

10.  Do monthly operating reports (MORs) and daily bench sheets report any of the following?

□ CT calculations

□ MCLs

□ filter run

□ filter rates

□ backwash rates

□ clear well capacity

□ chemical ppm

□ chemical amounts used

□ residuals

□ other __________________________

Comments:   ______________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

9.

If the violations have not been corrected explain why.   _____________________

_________________________________

_________________________________

_________________________________

_________________________________

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