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SMALL DRINKING WATER SYSTEM

Kentucky Peer Review Program – Self Evaluation

Water System Name _________________________________________________

Address ___________________________________________________________

County _______________________ ADD District _________________________

Phone ____________________________ Date ____________________________

WATER DISTRIBUTION

1.

What are the three most common complaints?

1.

_____________________________

_____________________________

2._____________________________

_____________________________

3._____________________________

_____________________________

2.

What is the water system line pressure? Average ______________ p.s.i.

Minimum _____________ p.s.i.

Maximum _____________ p.s.i.

3.   Are plans of the distribution system available and current?

□ Yes     □ No     □ Not Sure

4.

Do maps contain any of the following information? (Check all that apply)

□ Pipe size, type, location

□ Valve and blowoff locations

□ Storage tank size, location, elevations

□ Interconnections with other systems

□ Dead end lines

□ Oldest portion of pipe

□ Proposed construction

□ Hydrant locations

□ Sampling/monitoring sites

□ Other __________________________

5.

What is the typical free chlorine residual being maintained?  _____________ ppm

Is booster chlorination required?

□ Yes     □ No     □ Not Sure

6.

Have you experienced problems main-taining a residual chlorine level in the system?

□ Yes     □ No     □ Not Sure

7.

Is the system interconnected with any other water system?

□ Yes     □ No     □ Not Sure

8.

Does your system have a written and active cross connection prevention program?

□ Yes     □ No    □ Not Sure

9.

Is water loss calculated and recorded?

□ Yes     □ No     □ Not Sure

If “Yes” is calculation performed:

□  Monthly

□  Quarterly

□  Annually

□  Other _________________________

10.

Are there written standard operating procedures (SOP’s) for all tasks?

□ Yes     □ No     □ Not Sure

If “Yes” are the procedures followed?

□ Yes     □ No     □ Not Sure

11.

Is there a contingency plan for emergency situations?  (For example:  long term power outages, equipment failure, etc.)

□ Yes     □ No     □ Not Sure

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