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SMALL DRINKING WATER SYSTEM

Kentucky Peer Review Program – Self Evaluation

Water System Name _________________________________________________

Address ___________________________________________________________

County _______________________ ADD District _________________________

Phone ____________________________ Date ____________________________

SURFACE WATER SOURCES

1.

Are all permits available, such as water withdrawal, discharge, chemical handling, disposal, etc?

□ Yes     □ No     □ Not Sure

2.

What is the present average daily production?_______________________

3.

What is the maximum daily production? ________________________________

4.

Is the production sufficient to meet current and future demands?

□ Yes     □ No     □ Not Sure

5.

Is the facility operating within permit limits?

□ Yes     □ No     □ Not Sure

6.

Are all plans, specifications and chemical changes approved by the Division of Water?

□ Yes     □ No     □ Not Sure

7.

What percentage of production is “unaccounted for water”? _____ %

□ Not Sure

8.

Does the water system have an operational: Raw Water Meter?               □ Yes     □ No     

High Service Meter?  □ Yes     □ No

Master Meter?  □ Yes     □ No   

Have the above meters been calibrated?

□ Yes     □ No     □ Not Sure

Date of Calibration:  ____/____/____

9.

Number of service connections: ______ Population being served: _______

10.

Are the service connections metered?

□ Yes     □ No     

11.

Does the system have interconnections with neighboring systems?  

□ Yes     □ No     

If yes, list  ________________________

___________________________________________________________________________________________________

12.

Does the system have a contingency plan for service interruptions?

□ Yes     □ No

13.

Does the rate structure encourage water conservation?  (For example:  the more you use, the more you pay per 1000 gallons.)

□ Yes     □ No     

14.

Does the system have an adequate watershed protection program?

□ Yes     □ No     □ Not Sure

Describe status in comments section.

15.

Are there potential sources of pollution in close proximity to the intake?

□ Yes     □ No     □ Not Sure

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