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SMALL DRINKING WATER SYSTEM

Kentucky Peer Review Program – Self Evaluation

Water System Name _________________________________________________

Address ___________________________________________________________

County _______________________ ADD District _________________________

Phone ____________________________ Date ____________________________

WATER TREATMENT

1.

Do any of the following have the potential to present a water quality challenge for your system?

High turbidity after rains?

□ Yes     □ No     □ Not Sure

Fluctuations in pH?

□ Yes     □ No     □ Not Sure

Fluctuations in alkalinity?

□ Yes     □ No     □ Not Sure

Fluctuations in temperature?

□ Yes     □ No     □ Not Sure

Taste and odor problems?

□ Yes     □ No     □ Not Sure

High iron or manganese levels?

□ Yes     □ No     □ Not Sure

Man-made pollution? (Pesticides, nitrates, etc.)

□ Yes     □ No     □ Not Sure

2.

What special treatment processes are used to deal with these challenges? _________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

3.   Is chemical pretreatment required?

□ Yes     □ No     □ Not Sure

4.

Are all chemicals used in the treatment process ANSI/NSF approved?

□ Yes     □ No     □ Not Sure

5.

Is there at least a 30 day supply of chemicals on hand?

□ Yes     □ No     □ Not Sure

6.

List the chemicals used and typical dosages.

___________________      ______ ppm

___________________      ______ ppm

___________________      ______ ppm

___________________      ______ ppm

___________________      ______ ppm

7.

Are chemicals properly stored segregating incompatible chemicals?(For example:  store greases and oils separately from oxidizers such as permanganate or chlorine compounds, and separate these from other water treatment chemicals such as lime, fluoride, caustics, activated carbon, etc.)

□ Yes     □ No    □ Not Sure

8.

Are Material Safety Date Sheets (MSDS) available for all chemicals being used?

□ Yes     □ No     □ Not Sure

9.

What type of filter system is used?

□  Pressure

□  Green Sand

□  Rapid Sand

□  Slow Sand

□  Multi-media

□  None

□  Other ________________________    

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