J.1_BoulderOfficeWaterSystemSS_09-07-2018.pdf

Sanitary Survey – Boulder Ranger District Office September 7, 2018

W- 1

Parts I, II, and III

OFFICE, FIELD AND REPORT DATA FOR

SANITARY/CONDITION SURVEY

of a

DRINKING WATER SYSTEM

Water System Name : Boulder Ranger District Office

System Classification (Public, Non-Public) : Public, Non-Transient Non-Community

(NTNC)

Forest : Arapaho and Roosevelt National Forest and Pawnee National Grassland

District : Canyon Lakes Ranger District

Year of Survey (YYYY) 2018

Real Property Number 01600

Forest Service, or State or EPA I.D. Number: None (Hauled Potable Water)

W- 2

PART I

OFFICE DATA FOR SANITARY/CONDITION SURVEY

(DRINKING WATER)

Forest : Arapaho and Roosevelt National Forest and Pawnee National Grassland

District : Boulder Ranger District

Forest Service, or State or EPA I.D. Number: None (Hauled Potable Water)

Date Compiled (MM,DD,YY) : September 7, 2018

Data Compiled By : /s/ Chris Ida

INDEX

PART I

ITEM NO. PAGE

PART I - OFFICE DATA

Cover W-1 Index W-2 IA. Design and Construction Information W-3 IB. Water System Classification W-3 IC. Water Analysis Records W-4 ID. Baseline Testing W-5 IE. Potential Source of Contaminants W-7 IF. Certified Operator W-7 IG. Use Records

7. Water Meter Reading Worksheet

8. Electrical Meter Reading Worksheet

W-7 W-8 W-9

IH. Records

1. Operation and Maintenance

2. Sanitary/Condition Survey

3. Water Rights

4. Watershed

5. Record Retention

W-10 W-10 W-10 W-10 W-10 W-11

II. Annual Operation and Maintenance Worksheet - Drinking Water W-11

W- 3

PART I - OFFICE DATA

A. DESIGN AND CONSTRUCTION RECORDS

1. Engineering Report: YES (Y/N) When FEBRUARY 16, 1999

2. Design criteria: YES (Y/N)

3. Construction drawings and specifications: YES (Y/N)

4. "As-built" drawings: (If YES, provide copy) YES (Y/N)

5. Sketch: (If YES, provide copy) YES (Y/N)

6. Is there a site plan: (If YES, provide copy) YES (Y/N)

7. Final construction report: YES (Y/N)

8. Type of site served: ADMINISTRATIVE (Special Use, Admin, Recreation, Other)

9. When constructed: 1999

10. Modifications Since Construction: YES Describe:

a. 2008/2009 ADDITIONAL 2000 GALLON

BURIED WATER TANK ADDED IN

SERIES TO EXISTING

b.

Remarks: “COPIES” ARE IN DESIGN FOLDER AND NOT ATTACHED TO THIS

REPORT.

B. WATER SYSTEM CLASSIFICATION

1.

2.

3.

Maximum number of persons using the system per day:

How many days per year?

Use Period Signature & Date of Whom made Determination: CHRIS N. IDA 02/16/2018

26 ( ESTIMATED )

260 DAYS

YEAR-ROUND

4. Drinking water is what classification NTNC

5. Is the class in No. 4, the same as what the EPA or State have on file? N/A (Y/N)

6. Class Definitions

a. Public: (At least 25 people, at least 60 days per year, or 15 service connections)

1. Community (C) serves a residential population on a year-round basis.

2. Transient Non-Community (TNC)-Does not serve a residential population (campgrounds)

3. Non-Transient, Non-Community (NTNC)-Does not serve a residential population but does serve at least 25 of the same people over 6 months per year on a regular basis. (School, Office)

b. Non-Public (NP) (serves less than 25 people, 60 days/per year or 15 service connections

1. Non-Public, Transient (NPT)- Does not serve more than 25 persons less than 180 days.

(small picnic and campgrounds).

2. Non-Public, Non-Transient (NPNT) - serves less than 25 year-round residents or serving less than 25 persons more than 180 days per year. (smaller workstations and work centers)

W- 4

7. Water meter readings available: NO (Y/N)

8. Electrical meter readings available: NO (Y/N) (If YES, provide copy)

9. Water meter reading worksheet (See Page WI-8) NOT APPLICABLE

10. Electrical meter reading worksheet (See Page WI-9) NOT APPLICABLE

Remarks:

C. WATER ANALYSIS RECORDS

1. Classification - Public, Non-Transient, Non-Community, Ground Water (HAULED WATER)

Testing

1. Bacteriological:

A. Seasonal System-must monitor for total coliform 10 days prior to opening for season:

N/A (Y/N)

B. Monthly routine sample: YES (Y/N) C. Comments: MONTHLY SAMPLING DONE BY CERTIFIED

POTABLE WATER HAULING COMPANY (A-1 DISCOUNT)

2. Turbidity: NOT REQUIRED

3. Baseline Testing: NOT REQUIRED

4. Inorganics (IOCs): Generally not required except for nitrates.

A. Nitrate: Required every year B. Nitrate: Required once (before chlorination):

NO (Y/N)

NO (Y/N)

5. Palatability and Esthetic Acceptability A. Alkalinity: NO (Y/N) B. Hardness: NO (Y/N) C. PH (on site)** NO (Y/N) D. Iron** NO (Y/N) E. Manganese** NO (Y/N) F. Sulfide: NO (Y/N) **Requred under baseline testing

6. Organics:

A. (Herbs and Pests) SOC's (Required for systems specified by Health

Department)

NOT REQUIRED

B. THM's (Not Required) NOT REQUIRED C. VOC's (Required) NOT REQUIRED

7. Radioactivity: Not Required (Community Systems Only) NOT REQUIRED

8. Lead and Copper: NO (Y/N)

9. Disinfection: POTABLE WATER SOURCE IS CITY OF BOULDER YES (Y/N)

10. Has a Microscopic Particulate Analysis (MPA) been completed on this source:

If yes, when:

NO (Y/N)

11. Remarks: FOREST SERVICE TO MAINTAIN SEPARATE MONTHLY

BIOLOGICAL TEST RESULTS AND CHLORINE RESIDUAL TEST

RESULTS

W- 5

2. Classification - Public, or Non-Public (Transient) Non-Community, Ground, or Surface Water

Testing

1. Bacteriological:

A. Seasonal System-must monitor for total coliform 10 days prior to opening for season:

N/A (Y/N)

B. Monthly routine sample (USFS) N/A (Y/N) C. Comments:

2. Turbidity: (Not Required for Ground Water, Required for Surface): N/A (Y/N)

3. Baseline Testing: (See page W-5) SEE BELOW

4. Inorganics (IOCs): (Generally not required except ) A. Nitrate: Required every year: N/A (Y/N)

(EVERY 3

YEARS)

B. Nitrate: Required once (before chlorination): N/A (Y/N)

(REQUIRED

ONCE BEFORE

CHLORINATION)

5. Palatability and Esthetic Acceptability (USFS) A. Alkalinity N/A (Y/N) B. Hardness: N/A (Y/N) C. PH (on site)** N/A (Y/N) D. Iron** N/A (Y/N) E. Manganese** N/A (Y/N) F. Sulfide: N/A (Y/N) **Required under baseline testing

6. Organics:

A. Herbs and Pests (Not Required) N/A (Y/N) B. THM's (Not Required) N/A (Y/N) C. VOC's (Not Required) N/A (Y/N) D. Unreq. VOC's (Not Required) N/A (Y/N) E. SOC's (Not Required) N/A (Y/N)

7. Radioactivity (Not Required) N/A (Y/N)

8. Lead and Copper (Not Required) N/A (Y/N)

9. Disinfection: N/A (Y/N)

10. Has a Microscopic Particulate Analysis been completed on this source:

If yes, when N/A (Y/N)

11. Remarks:

D. BASELINE TESTING

FSM 7421.24a requires a baseline testing of all potable water systems (no class differentiation) to analyze for all primary and secondary inorganic and organic contaminants listed in the National Interim Primary Drinking Water Regulations, National Secondary Drinking Water Regulations

(NSDWR).

W- 6

1. Primary Drinking Regulations

A. Inorganic Contaminants – Date Tested:

1. Arsenic: NO (Y/N)

2. Barium: NO (Y/N)

3. Cadmium: NO (Y/N)

4. Chromium: NO (Y/N)

5. Lead: NO (Y/N)

6. Mercury: NO (Y/N)

7. Nitrate (as N): NO (Y/N)

8. Selenium: NO (Y/N)

9. Silver: NO (Y/N)

10. Fluoride: NO (Y/N) B. Organic Contaminants: - Date Tested:

1. Chlorinated Hydrocarbons A. Endrin: NO (Y/N) B. Lindane: NO (Y/N) C. Methoxychlor: NO (Y/N) D. Toxaphene: NO (Y/N)

2. National Secondary Drinking Water Regulations (NSDWR) A. Aluminum: NO (Y/N) B. Chloride: NO (Y/N) C. Color: NO (Y/N) D. Copper: NO (Y/N) E. Corrosivity: NO (Y/N) F. Foaming Agent: NO (Y/N) G. Iron: NO (Y/N) H. Manganese: NO (Y/N) I. Odor: NO (Y/N) J. PH (At Site): NO (Y/N) K. Sulfate: NO (Y/N) L. Silver: NO (Y/N) M. TDs NO (Y/N) N. Zinc: NO (Y/N)

Remarks: A COMPLETE BASELINE CHEMICAL ANALYSIS SHOULD BE OBTAINED ON

THIS SITE’S HAULED WATER SOURCE.

W- 7

E. POTENTIAL SOURCE OF CONTAIMINANT WITHIN ONE HALF MILE OF A

WATER SOURCE

1. Agricultural Run-off: NO (Y/N)

2. Animal Feed Lots or Grazing: NO (Y/N)

3. Wastewater Treatment Plant Discharge NO (Y/N)

4. Hazardous Waste Site: NO (Y/N)

5. Solid Waste Disposal: NO (Y/N)

6. Pesticides, Rodenticides, Fungisides NO (Y/N)

7. Mining, Oil, or Gas Activities NO (Y/N)

8. Petroleum Products (eg., auto repair shop, gas station

(MTBE)):

NO (Y/N)

9. Septic System or other Wastewater System: YES (Y/N) APPROX. 335 FEET

10. Is there a Source Water Protection Plan: NO (Y/N)

11. Logging in Last 10 Years: NO (Y/N)

12. Other (Please specify): NONE (Y/N)

13. Forest Fire in Last 10 Years: NO (Y/N))

14. Remarks:

Note: If any of 1-9 are yes, note size, distance, protection measures, sources, and system components.

F. CERTIFIED OPERATOR: YES (Y/N)

1. Name STEVEN J. WOOD

2. License No. 36397

3. Class S-WATER SYSTEMS

G USE RECORDS

1. Water Shortage experienced: (If YES, explain): NO (Y/N)

2. Water meter readings available (If YES, provide copy): NO (Y/N)

3. Electrical meter readings available (If YES, provide copy): NO (Y/N)

4. Water meter reading worksheet (See Page WI-8): NONE (Y/N)

5. Electrical meter reading worksheet (See Page WI-9): N/A (Y/N)

6. Remarks: NO WATER METER OR SEPARATE ELECTRICAL METER. WATER

STORAGE TANK IS FILLED ON A SCHEDULED BASIS. PROVIDER IS A-1

DISCOUNT (303-440-5728).

W- 8

7. Water Meter Readings Worksheet (Last 5 Years)

MONTH/YEAR READING

(GALLONS OR

CUBIC FEET

USED (GALLONS

OR CUBIC FEET)

COST ($)

1. NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

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25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

W- 9

8. Electrical Meter Readings Worksheet (Last 5 Years)

MONTH/YEAR

USE (KW)

COSTS ($)

1. NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

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27.

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29.

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31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

W- 10

H. RECORDS

1. Operation and Maintenance

a. Scheduled operation and maintenance adequate NO (Y/N)

b. Preventive maintenance: NO (Y/N)

c. O&M records adequate: NO (Y/N)

d. O&M manual available: NO (Y/N)

e. Is there a maintenance log book?: NO (Y/N)

f. Maintenance responsibilities clearly defined: NO (Y/N)

g. Is there a sampling site plan: NO (Y/N)

h. Is there a cross-connection control plan: NO (Y/N)

Improvements needed: NEED OPERATIONS AND MAINTENANCE PLAN AND

DOCUMENT PREVENTATIVE MAINTENANCE ACTIVITIES.

2. Sanitary Surveys:

a. Reason for Sanitary/Condition Survey: ROUTINE (Initial, Routine, Compliance)

b. Previous Sanitary/Condition Surveys YES (Y/N)

(MM DD YY) 08/06/2012

3. Water Rights

a. Are there water rights: NOT APPLICABLE (Y/N)

b. Water right name: NOT APPLICABLE (Y/N)

c. State File No.: NOT APPLICABLE (Y/N)

d. Reserved water rights claimed: NOT APPLICABLE (Y/N)

Remarks: HAULED POTABLE WATER FROM CITY OF BOULDER MUNICIPAL

WATER SYSTEM

4. Watershed

a. Watershed name: NOT APPLICABLE

b. Watershed code: NOT APPLICABLE

Remarks: HAULED POTABLE WATER FROM CITY OF BOULDER MUNICIPAL

WATER SYSTEM

W- 11

4. Record Retention--Are the following records being retained:

Records

Time Period

a. Sanitary/Condition Surveys 10 Years YES (Y/N)

b. Bacteriological Analysis 5 Years NO (Y/N)

c. Chemical Analysis *10 Years NO (Y/N)

d. Physical Analysis *10 Years NO (Y/N)

d. Variances or Exemptions 5 Years NO (Y/N)

e. Turbidity Results 10 Years N/A (Y/N)

f. Violations 37 Years NO (Y/N)

*Life of system, unless a flood, earthquake, etc.)

I. ANNUAL OPERATIONS & MAINTENANCE WORKSHEET – DRINKING WATER

Key to Deferred Maintenance Tasks

Task Description Dollars Needed

Unit Remarks

01 Start Up 01-005001 Start Up - Storage - Flush and Fill Pressure Tanks

$34.09 HOUR 1 HOUR

01 Start Up 01-005002 Start Up - Storage - Disinfect Storage Tank

$40.46 EACH 1 HOUR

03 Operator Training & Certification

03-001001 Operator Training & Certification - Office - Seasonal Training

$272.73 EACH 8 HOURS

03 Operator Training & Certification

03-001002 Operator Training & Certification - Office - Confined Space Awareness Training

$68.18 EACH 2 HOURS

06 Condition Survey

06-001001 Condition Survey - Survey - Beginning of Season Inspection

$136.36 HOUR 4 HOURS

06 Condition Survey

06-001002 Condition Survey - Survey - End of Season Survey

$136.36 HOUR 4 HOURS

07 Sanitary Survey

07-001002 Sanitary Survey Survey - Surveys - Sanitary Survey/Condition Survey (FOREST

SERVICE)

$403.69 EACH 8 HOURS

08 System Operation

08-002001 System Operation - Pumps and Controls - Weekly Check

$409.09 HOUR 12 HOURS OVER

THE YEAR

10 Sampling 10-002002 Sampling - Source - Monthly Bacteriological Test

$714.61 EACH 12 TESTS OVER

THE YEAR

10 Sampling 10-003001 Sampling - Treatment - Chlorine Residual Test

$409.09 HOUR 12 TESTS OVER

THE YEAR

11 Record Keeping

11-001001 Record Keeping - Office - INFRA Updates

$272.73 HOUR 8 HOURS

11 Record Keeping

11-001002 Record Keeping - Office - Water Quality Reports

$272.73 HOUR 8 HOURS

11 Record Keeping

11-001003 Record Keeping - Office - Well logs/As-Builts/O&M and Sampling Plans

$1,273.00 LS None

W- 12

PART II

FIELD DATA FOR SANITARY/CONDITION SURVEY

Pawnee National Grassland

District : Boulder Ranger District

Forest Service, or State or EPA I.D. Number: None (Hauled Potable Water)

Date Surveyed : September 7, 2018

Surveyed By : /s/ Chris Ida

PART II

ITEM NO. PAGE

PART II - FIELD DATA

IIA. Source W-12

1. Well W-14

2. Spring W-14

3. Surface W-14

4. Municipal W-15

IIB. Pumps W-15

1. Well W-15

2. Supply W-16

3. Handpump W-17

IIC. Treatment System W-18 IID. Storage System W-18 IIE. Distribution System W-20 IIF. Point of Use W-20 IIG. Electrical System W-26

W- 13

PART II - FIELD DATA

A. SOURCE

1. Well

a. Well permit number:

b. Well log: N/A (Y/N)

c. Location:

Latitude:

Longitude:

Section:

Township:

Range:

d. Type: (Dug, Driven, Jetted, Bored, Drilled)

e. Casing:

Diameter: (inches, I.D) Material: (Plastic, Steel, Other) Wall thickness: (inches)

f. Depth:

Ground surface to bottom of well: (FEET) Ground surface to bottom of casing: (FEET) Ground surface to first draw (top of screen/perforations or bottom of casings)

(FEET)

Static water level: (FEET) Pump set at (FEET)

g. Capacity (gpm at feet drawdown)

h. Type of sanitary seal: (Cement Grout, Bentonite, Well Cutting, Other)

i. Subject to flooding: N/A (Y/N)

j. Has well been evaluated for 100 year flood: N/A (Y/N)

k. Is casing 18 inches above natural grade:

N/A (Y/N)

l. Concrete slab around casing: N/A (Y/N)

m. Well screen Material: (Plastic, Steel, Other) Type: (Slotted, Drilled, Torch Cut) Hole/Slot Size:

n. Sanitary well cover type: (Cap, Seal) Vented:

o. Pitless Adapter: N/A (Y/N)

p. Located how far from a possible source of contamination

(subsurface sewage disposal field, septic tank, vault toilet, stream, lake, marsh or ditch)

(FEET)

q. Has a microscope particulate analysis (MPA) been completed on this source:

If Yes, When: (mm/dd/yy)

N/A (Y/N)

Condition: (Critical, Poor, Satisfactory, Good) Appraisal: (Maintain, Remove, Repair, Replace)

W- 14

Possible sources of contamination:

Improvements needed:

2. Spring

a. Location:

Latitude:

Longitude:

Section:

Township:

Range:

b. Type: (Flowing, Non-flowing, Intermittent)

c. Estimated minimum capacity (GPM)

d. Surface drainage controlled: (Y/N)

e. Adequate fencing around spring: (Y/N)

f. Spring box watertight: (Y/N)

g. Spring box cover:

1. Lockable: (Y/N)

2. Watertight: (Y/N)

3. Overhanging (shoe box lid): (Y/N)

4. Material: (Concrete, Steel, Other) (Y/N)

5. Gasket adequate: (Y/N)

h. Spring box vent screened: (Y/N)

i. Spring box drain screened: (Y/N)

j. Spring box - has overflow and drain pipe: (Y/N)

k. Spring/well permit number:

l. Does spring box have laterals or open gravel bottom (Y/N)

m. Has a microscopic Particulate Analysis (MPA) been completed on this source? If Yes, When: (MM/DD/YY) (Y/N)

Condition: (Critical, Poor, Satisfactory, Good) Appraisal: (Maintain, Remove, Repair, Replace)

Possible sources of contamination in watershed: (pesticide usage, logging, spills, or grazing):

3. Surface (Stream, River, or Lake)

a. Name (s) :

Location:

Latitude:

Longitude:

Section:

Township:

Range:

b. Flow: (Perennial or Intermittent)

c. Upstream human activity on watershed: (Y/N)

W- 15

d. Intake structure or impoundment provided: (Y/N)

e. Intake structure overflow and drain provided: (Y/N)

f. Intake screened: (Y/N)

g. Intake inaccessible to public: (Y/N)

h. Impoundment easily cleaned of sedimentation and debris: (Y/N)

i. Collection Method: (Infiltration Gallery, Surface Intake) Condition: (Critical, Poor, Satisfactory, Good) Appraisal: (Maintain, Remove, Repair, Replace)

Possible sources of contamination in watershed: (pesticide usage, logging, spills, grazing or fires)

4. Municipal:

a. Name of Water System: A-1 DISCOUNT

b. Water System I.D. Number: NONE (HAULED

WATER

c. Name of Owner: A-1 DISCOUNT

d. Have there been any reports of waterborne disease: If

Yes, give details

NO (Y/N)

e. Have there been any violations in the past 3 years:

If Yes, What:

NO (Y/N)

f. Water Source: (Ground, Spring, Surface) MUNICIPAL

B. PUMPS:

1. Well

a. Manufacturer: GOULDS

b. Model: 18GS10422

c. Diameter: 4”

d. Horsepower: 1 HP

e. RPM: 3450

f. FLA: UNKNOWN

g. S.F.: UNKNOWN

h. Voltage: UNKNOWN

i. Phase: UNKNOWN

j. Running Time Meter: (hrs) ## (HOURS)

k. Pump Operational Counter: (counts) ## (COUNTS)

l. Operating properly: YES (Y/N)

m. Pump properly sized: YES (Y/N)

n. Pump curve provided: NO (Y/N)

o. Pumping Rate Capacity: UNKNOWN (Y/N)

p. Year of Installation: 1999 (Y/N)

q. Pump protection:

1. Conductors to motor properly sized: YES (Y/N)

2. Motor running current below nameplate rating: YES (Y/N)

3. Circuit breaker or fuse properly sized: YES (Y/N)

4. Motor starter overloads properly sized: YES (Y/N))

5. Motor starter properly sized: YES (Y/N)

W- 16

6. Hand-off-Automatic switch: NONE (Y/N)

7. Operation light: NONE (Y/N)

8. Pump operation timer: NONE (Y/N)

9. Start and stop pump controls adequate: YES (Y/N)

10. Low liquid level shutoff (Storage tank system) NONE (Y/N)

11. Low water level shut off in well: NONE (Y/N)

r. Pump discharge piping:

1. Pressure gauge with shutoff: NO (Y/N)

2. Check valve: YES (Y/N)

3. Control and shutoff valve: YES (Y/N)

4. Flow control valve: NONE (Y/N)

00 (GPM)

5. Pressure Relief Valve: NO (Y/N) Setting: ## (PSI)

6. Pressure Regulating Valve YES (Y/N) Setting: 30-50 (PSI) Condition: (Critical, Poor, Satisfactory, Good) GOOD Appraisal: (Maintain, Remove, Repair, Replace) MAINTAIN

2. Supply Pump (If there is a separate well and supply pump.)

a. Manufacturer:

b. Model:

c. Horsepower:

d. RPM:

e. FLA:

f. S.F.:

g. Voltage:

h. Phase:

i. Running Time Meter: (hrs) ## (HOURS)

j. Pump Operation Counter: (counts) ## (COUNTS)

k. Operating properly: (Y/N)

l. Pump properly sized: (Y/N)

m. Pump curve provided: (Y/N)

n. Pumping Rate Capacity: (Y/N)

o. Year of Installation: (Y/N)

p. Pump protection:

1. Conductors to motor properly sized: (Y/N)

2. Motor running current below nameplate rating: (Y/N)

3. Circuit breaker or fuse properly sized: (Y/N)

4. Motor starter overloads properly sized: (Y/N)

5. Motor starter properly sized: (Y/N)

6. Hand-off-Automatic switch: (Y/N)

7. Operation light: (Y/N)

8. Pump operation counter: (Y/N)

9. Start and stop pump controls adequate: (Y/N)

10. Low liquid level shutoff (Storage tank system) (Y/N)

W- 17

q. Pump discharge piping:

1. Pressure gauge with shutoff: (Y/N)

2. Check valve type: (Swing, Poppet, Disk)

3. Control and shutoff valve: (Y/N)

4. Flow control valve: ## (GPM) Condition: (Critical, Poor, Satisfactory, Good) Appraisal: (Maintain, Remove, Repair, Replace)

3. Handpump

a. Drainage

1. Drain pipe or trough clean: NONE (Y/N)

2. Excess water drains away from slab area: NONE (Y/N)

3. Surface water drains away from slab area: NONE (Y/N)

b. Slab

1. Open cracks in slab: NONE (Y/N)

2. Rodents burrowing under slab: NONE (Y/N)

3. Is there an open gap between the well casing and the slab: NONE (Y/N)

c. Pump Stand

1. Nuts and bolts on stand are tight: NONE (Y/N)

2. Pump secured to concrete slab or casing: NONE (Y/N)

d. Packing Nut and Packing (Stuffing Box)

1. Is there packing: NONE (Y/N)

2. Packing nut tight (tightened enough so there is no side movement):

NONE (Y/N)

3. Is packing in good condition: NONE (Y/N)

e. Upper Piston Guide

1. Is there more than 1/8 inch of play between guide and rod in the direction of the pump handle:

NONE (Y/N)

f. Pump Flanges

1. Check for presence of flange gasket. Can usually tell by gap between flanges and probing with a knife:

NONE (Y/N)

2. Is gasket in good condition? No cracks, etc: NONE (Y/N)

g. 1. Is pump located near a stream, lake, marsh, septic system, or toilet, etc:

NONE (Y/N)

2. How far from one of the above: NONE

h. Bubble reservoir clean: NONE (Y/N)

i. If pump outlet pipe is threaded, is there an anti-siphon device used:

NONE

j. Is a shroud installed on the pump: NONE (Y/N)

k. Year of installation: NONE Condition: (Critical, Poor, Satisfactory, Good) Appraisal: (Maintain, Remove, Repair, Replace) Possible sources of contamination:

W- 18

C. TREATMENT SYSTEM - HAULED POTABLE WATER FROM CITY OF BOULDER

1. Type of disinfection: (Chlorine, Iodine, Ozone, Other) NONE

2. Sedimentation: N/A (Y/N)

3. Filtration: N/A (Y/N)

4. Filter material: (Sand or Other medium) N/A

5. Equipment Flow Rate: YES

6. Treatment being provided in accordance with FSM 7420 and State

Drinking Water Design Criteria:

N/A (Y/N)

7. Treatment equipment adequate: N/A (Y/N)

8. Treatment equipment operating properly: N/A (Y/N)

9. Test equipment adequate: N/A (Y/N)

10. Disinfection contact time adequate: N/A (Y/N)

11. Treatment building or enclosure:

a. Inaccessible to public: N/A (Y/N)

b. Ventilation adequate: N/A (Y/N)

c. Heating adequate: N/A (Y/N)

d. Drainage adequate: N/A (Y/N)

12. Disinfection Unit: NO (Y/N)

a. Manufacturer Phone No.

b. Model Number:

c. Discharge Flow: (gals./day) 00 (GALS/DAY)

d. Spare parts: N/A (Y/N)

e. Records kept of disinfectant residual N/A (Y/N)

f. Type (Pressure, Water, Electric, Tablet, Other)

g. Protective equipment available:

1. Rubber gloves: N/A (Y/N)

2. Face Shield: N/A (Y/N)

3. Eye Bath: N/A (Y/N)

h. Testing chlorine residual for total chlorine: N/A (Y/N)

13. Disinfection monitor waiver: N/A (Y/N) Condition: (Critical, Poor, Satisfactory, Good) Appraisal: (Maintain, Remove, Repair, Replace) Improvements:

Remarks:

D. STORAGE SYSTEM

1. Tank Type: (Hydropneumatic, Elevated, Below Ground) TWO BELOW

GROUND STORAGE

TANKS

Manufacturer: XERXES Model No:

2. Material of construction: (Steel, Concrete, Wood, Fiberglass, Polyethylene)

FIBERGLASS

3. Capacity adequate for:

a. Domestic: YES (Y/N)

b. Fire: NO (Y/N)

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c. Irrigation: NO (Y/N)

d. Capacity: 2000/3000 (GALS)

e. Dimensions: (l x w x h) inches

4. Vent with return bend and screened: YES (Y/N)

5. Is screen size 24 mesh or smaller: YES (Y/N)

6. Outlet through tank bottom: YES (Y/N)

7. Outlet off the bottom: YES (Y/N)

8. Tank inlet and outlet separate: YES (Y/N)

9. Tank inlet and outlet insulated: NO (Y/N)

10. Overflow pipe provided: NO (Y/N)

11. Overflow properly daylighted and screened: N/A (Y/N)

12. Tank drain through bottom YES (Y/N)

13. Tank drain separate from inlet and outlet: YES (Y/N) 14 Drain properly daylighted and screened: YES (Y/N)

15. Access cover:

a. Lockable: YES (Y/N)

b. Watertight: YES (Y/N)

c. Overhanging (shoebox type): NO (Y/N)

d. If bolted, are all the bolts in place: YES (Y/N)

e. Is gasket adequate: YES (Y/N)

16. Exterior ladder serviceable:

a. Climb prevention device adequate: NONE (Y/N)

17. Interior ladder:

a. Provided: NO (Y/N)

b. Serviceable: N/A (Y/N)

18. Roof watertight: N/A (Y/N)

19. Steel tanks:

a. Interior paint adequate: N/A (Y/N)

b. Exterior paint adequate: N/A (Y/N)

20. Concrete tanks:

a. Protective coating adequate: N/A (Y/N)

b. Concrete watertight: N/A (Y/N)

c. Tank interior painting system NSF of ANSI approved: N/A (Y/N)

21. Liquid level controls adequate: NONE (Y/N)

22. Level control type: (Probes, Floats) PRESSURE SWITCH

23. Level control manufacturer: SQUARE D

24. Level control model number: NOT APPLICABLE

25. Low level alarm provided: LIGHT ON TOP OF TANK YES (Y/N)

26. Volume gauge provided: NO (Y/N)

27. Pressure relief valve on hydropneumatic tank: YES (Y/N)

a. Is the valve sized properly: YES (Y/N)

28. Confined space plan in place for this tank: NO (Y/N) Condition: (Critical, Poor, Satisfactory, Good) GOOD Appraisal: (Maintain, Remove, Repair, Replace) MAINTAIN

Improvements: CONVERT TO MUNICIPAL SOURCE WHEN FEASIBLE.

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E. DISTRIBUTION SYSTEM

1. Pipe material: (PVC, Polyethylene, Ductive Iron, Copper) PVC, COPPER

2. Approximate length of piping system UNKNOWN (FEET)

3. Pressure at all fixtures adequate: YES (Y/N) If no, explain:

4. Pressure rating/other: (PSI Pressure Rating, SDR, Class, or

Schedule)

UNKNOWN

5. Pressure regulator provided: YES (Y/N)

6. Air relief valve (s) provided: NO (Y/N)

7. Vacuum relief valve (s) provided: NO (Y/N)

8. Drains to daylight: YES (Y/N)

9. Pumped Drain: NO (Y/N)

10. Drains screened: UNKNOWN (Y/N)

11. Lines adequately buried: YES (Y/N)

12. Water pipe NSF approved: YES (Y/N)

13. Adequate coverage with fire hydrants: N/A (Y/N)

14. Water hammer arrestors provided: NO (Y/N)

15. Water meter provided: YES (Y/N)

16. Tap for obtaining sample of raw water provided: YES (Y/N)

17. Access point for adding disinfectant provided: NO (Y/N)

18. Valve pits - free of water: N/A (Y/N)

19. Is there an interconnection with any other system: NO (Y/N) If yes, explain: (Y/N) Condition: (Critical, Poor, Satisfactory, Good) GOOD Appraisal: (Maintain, Remove, Repair, Replace) MAINTAIN

Possible sources of contamination:

Improvements:

Remarks:

F. POINT OF USE

1. Type: (Hydrant, Fountain, Hydrant & Fountain) MAIN OFFICE. PUBLIC WATER

FOUNTAINS (TWO)

a. Manufacturer: ELKAY Phone: 708-574-8484

b. Model No: EBFATL-8 c.. Accessibility Status: (Not-Accessible, Usable, Accessible) ACCESSIBLE

d. Drainage:

1. Drain pipe or trough clean: NONE (Y/N)

2. Excess water drains away from slab area: NONE (Y/N)

3. Surface water drains away from slab area: NONE (Y/N)

e. Slab:

1. Open cracks in slab: NONE (Y/N)

2. Rodents burrowing under slab: NONE (Y/N) Condition: (Critical, Poor, Satisfactory, Good) GOOD Appraisal: (Maintain, Remove, Repair, Replace) MAINTAIN

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Type: (Hydrant, Fountain, Hydrant & Fountain) MAIN OFFICE. EMPLOYEE WATER

FOUNTAINS (TWO)

a. Manufacturer: ELKAY Phone: 708-574-8484

b. Model No: EBFATL-8 c.. Accessibility Status: (Not-Accessible, Usable, Accessible) ACCESSIBLE

d. Drainage:

1. Drain pipe or trough clean: NONE (Y/N)

2. Excess water drains away from slab area: NONE (Y/N)

3. Surface water drains away from slab area: NONE (Y/N)

e. Slab:

1. Open cracks in slab: NONE (Y/N)

2. Rodents burrowing under slab: NONE (Y/N)

Type: (Hydrant, Fountain, Hydrant & Fountain) MAIN OFFICE. PUBLIC BATHROOMS

(MENS AND WOMENS-1 LAVATORY,

1 TOILET)

a. Manufacturer: CRANE/DELTA Phone:

b. Model No: LAVATORY-CRANE

FAUCET-DELTA

1-412V

520-WFHGMHDE

c.. Accessibility Status: (Not-Accessible, Usable, Accessible) ACCESSIBLE

d. Drainage:

1. Drain pipe or trough clean: NONE (Y/N)

2. Excess water drains away from slab area: NONE (Y/N)

3. Surface water drains away from slab area: NONE (Y/N)

e. Slab:

1. Open cracks in slab: NONE (Y/N)

2. Rodents burrowing under slab: NONE (Y/N)

Type: (Hydrant, Fountain, Hydrant & Fountain) MAIN OFFICE. EMPLOYEE

BATHROOMS (MENS- 1 LAVATORY,

1 TOILET, 1 URINAL, 1 SHOWER)

a. Manufacturer: CRANE/DELTA Phone:

b. Model No: LAVATORY-CRANE

FAUCET-DELTA

SHOWER-FLORESTONE

1-280V

520-WFHGMHDE

40-40H c.. Accessibility Status: (Not-Accessible, Usable, Accessible) ACCESSIBLE

d. Drainage:

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1. Drain pipe or trough clean: NONE (Y/N)

2. Excess water drains away from slab area: NONE (Y/N)

3. Surface water drains away from slab area: NONE (Y/N)

e. Slab:

1. Open cracks in slab: NONE (Y/N)

2. Rodents burrowing under slab: NONE (Y/N)

Type: (Hydrant, Fountain, Hydrant & Fountain) MAIN OFFICE. EMPLOYEE

BATHROOMS (WOMENS-

1 LAVATORY, 2 TOILET, 1 SHOWER)

a. Manufacturer: CRANE/DELTA Phone:

b. Model No: LAVATORY-CRANE

FAUCET-DELTA

SHOWER-FLORESTONE

1-280V

520-WFHGMHDE

40-40H c.. Accessibility Status: (Not-Accessible, Usable, Accessible) ACCESSIBLE

d. Drainage:

1. Drain pipe or trough clean: NONE (Y/N)

2. Excess water drains away from slab area: NONE (Y/N)

3. Surface water drains away from slab area: NONE (Y/N)

e. Slab:

1. Open cracks in slab: NONE (Y/N)

2. Rodents burrowing under slab: NONE (Y/N)

Type: (Hydrant, Fountain, Hydrant & Fountain) MAIN OFFICE. CONFERENCE ROOM

SINK

a. Manufacturer: MOEN Phone: 800-321-8809

b. Model No: CONFERENCE ROOM SINK FAUCET-MOEN #8901 c.. Accessibility Status: (Not-Accessible, Usable, Accessible) ACCESSIBLE

d. Drainage:

1. Drain pipe or trough clean: NONE (Y/N)

2. Excess water drains away from slab area: NONE (Y/N)

3. Surface water drains away from slab area: NONE (Y/N)

e. Slab:

1. Open cracks in slab: NONE (Y/N)

2. Rodents burrowing under slab: NONE (Y/N)

Type: (Hydrant, Fountain, Hydrant & Fountain) MAIN OFFICE. EMPLOYEE KITCHEN

W- 23

a. Manufacturer: MOEN Phone: 800-321-8809

b. Model No: EMPLOYEE KITCHEN SINK FAUCET-MOEN #8720 c.. Accessibility Status: (Not-Accessible, Usable, Accessible) ACCESSIBLE

d. Drainage:

1. Drain pipe or trough clean: NONE (Y/N)

2. Excess water drains away from slab area: NONE (Y/N)

3. Surface water drains away from slab area: NONE (Y/N)

e. Slab:

1. Open cracks in slab: NONE (Y/N)

2. Rodents burrowing under slab: NONE (Y/N)

Type: (Hydrant, Fountain, Hydrant & Fountain) MAIN OFFICE. UTILITY ROOM SINK

a. Manufacturer: FIAT/CRANE Phone: 800-442-1902

b. Model No: UTILITY ROOM SINK FAUCET-FIAT #830-AA c.. Accessibility Status: (Not-Accessible, Usable, Accessible) USABLE

d. Drainage:

1. Drain pipe or trough clean: NONE (Y/N)

2. Excess water drains away from slab area: NONE (Y/N)

3. Surface water drains away from slab area: NONE (Y/N)

e. Slab:

1. Open cracks in slab: NONE (Y/N)

2. Rodents burrowing under slab: NONE (Y/N)

Type: (Hydrant, Fountain, Hydrant & Fountain) MAIN OFFICE. OUTDOOR HYDRANTS

a. Manufacturer: JAY R SMITH Phone: 800-467-6484

b. Model No: OUTDOOR FAUCETS-JAY R SMITH #5511 c.. Accessibility Status: (Not-Accessible, Usable, Accessible) USABLE

d. Drainage:

1. Drain pipe or trough clean: NONE (Y/N)

2. Excess water drains away from slab area: NONE (Y/N)

3. Surface water drains away from slab area: NONE (Y/N)

e. Slab:

1. Open cracks in slab: NONE (Y/N)

2. Rodents burrowing under slab: NONE (Y/N)

Type: (Hydrant, Fountain, Hydrant & Fountain) EXTENSION OFFICE. EMPLOYEE

BATHROOMS (MENS AND WOMENS-

1 LAVATORY, 1 TOILET)

W- 24

a. Manufacturer: UNKNOWN Phone: UNKNOWN

b. Model No: LAVATORY-

FAUCET-

UNKNOWN

UNKNOWN

c.. Accessibility Status: (Not-Accessible, Usable, Accessible) ACCESSIBLE

d. Drainage:

1. Drain pipe or trough clean: NONE (Y/N)

2. Excess water drains away from slab area: NONE (Y/N)

3. Surface water drains away from slab area: NONE (Y/N)

e. Slab:

1. Open cracks in slab: NONE (Y/N)

2. Rodents burrowing under slab: NONE (Y/N)

Type: (Hydrant, Fountain, Hydrant & Fountain) EXTENSION OFFICE. EMPLOYEE

BREAKROOM SINK

a. Manufacturer: UNKNOWN Phone: UNKNOWN

b. Model No: BREAKROOM SINK FAUCET- UNKNOWN c.. Accessibility Status: (Not-Accessible, Usable, Accessible) ACCESSIBLE

d. Drainage:

1. Drain pipe or trough clean: NONE (Y/N)

2. Excess water drains away from slab area: NONE (Y/N)

3. Surface water drains away from slab area: NONE (Y/N)

e. Slab:

1. Open cracks in slab: NONE (Y/N)

2. Rodents burrowing under slab: NONE (Y/N)

Type: (Hydrant, Fountain, Hydrant & Fountain) EXTENSION OFFICE. UTILITY ROOM

a. Manufacturer: UNKNOWN Phone: UNKNOWN

b. Model No: UTILITY ROOM SINK FAUCET- UNKNOWN c.. Accessibility Status: (Not-Accessible, Usable, Accessible) USABLE

d. Drainage:

1. Drain pipe or trough clean: NONE (Y/N)

2. Excess water drains away from slab area: NONE (Y/N)

3. Surface water drains away from slab area: NONE (Y/N)

e. Slab:

1. Open cracks in slab: NONE (Y/N)

2. Rodents burrowing under slab: NONE (Y/N)

W- 25

Host Site Hydrant

Phone:

b. Model No:

c. Accessibility Status:(Not-Accessible, Usable, Accessible)

d. Number of Host Sites:

e. How Many have water:

f. Drainage:

1.Drain pipe or trough clean: NONE (Y/N) 2.Excess water drains away from slab area: NONE (Y/N) 3.Surface water drains away from slab area: NONE (Y/N)

g. Slab:

1.Open cracks in slab: NONE (Y/N) 2.Rodents burrowing under slab: NONE (Y/N) Condition: (Critical, Poor, Satisfactory, Good) Appraisal: (Maintain, Remove, Repair, Replace)

Improvements:

3. RV Site Hydrant

Phone:

b. Model No:

c. Accessible Status: (Not-Accessible, Usable, Accessible)

d. Number of RV sites:

e. How many have water:

Condition: (Critical, Poor, Satisfactory, Good)

4. Trailer Dump Station Tower (Drinking Water)

Phone no:

b. Model No:

c. Does the drinking water tower have a backflow device: (Y/N) Condition: (Critical, Poor, Satisfactory, Good)

5. If the outlets are threaded, are there any backflow prevention devices used: YES (Y/N)

a. If Yes, manufacturer: JAY R. SMITH Phone: 800-467-6484

b. Model No: #5511

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6. Are frost proof Hydrants NSF approved: (Y/N)

Phone:

b. Model No:

Condition: (Critical, Poor, Satisfactory, Good)

7. If this system serves any stock watering tanks, is there backflow prevention:)

Note: (Air gaps are not approved Backflow Prevention) Possible Sources of Contamination:

Improvements Needed:

G. ELECTRICAL SYSTEM

1. Power Source:

a. Utility Name: EXCEL ENERGY OF

COLORADO

Phone No.: 303-615-5000

1. Characteristics:

Voltage: 120/240 Overhead: NO (Y/N) Underground: YES (Y/N)

2. Transformer:

Ownership EXCEL ENERGY OF

COLORADO

Voltage: 120/240 Phase: SINGLE/THREE Capacity: 100 KVA Impedance: UNKNOWN

b. Generator Manufacturer:

Phone No:

Model:

Rating: (KW 120/240, phases)

c. Photovoltaic:

Panel Manufacturer Phone No:

Number of Panels:

Watts (ea):

Size:

2. Distribution: (From Meter) (Overhead/Underground): UNDERGROUND

W- 27

3. Host Site Power

a. Power Pedestal or box:

1. Manufacturer:

Phone:

2. Model No.:

3. How many host sites:

4. How many have power:

5. Main receptacle amperage:

6. Receptacle amperage:

Condition: (Critical, Poor, Satisfactory, Good) Appraisal: (Maintain, Remove, Repair, Replace)

4. RV Site Power

a. Power pedestal or box:

1. Manufacturer:

Phone:

2. Model No.:

3. How many host sites:

4. How many have power:

5. Main receptacle amperage:

6. Receptacle amperage:

Condition: (Critical, Poor, Satisfactory, Good) Appraisal: (Maintain, Remove, Repair, Replace)

W- 28

PART III

REPORT ON SANITARY/CONDITION SURVEY

(A copy of the Sanitary/Condition Survey, Parts I, II, and III, should be attached to this report.)

Pawnee National Grassland

District : Boulder Ranger District

Forest Service, or State or EPA I.D. Number: None (Hauled Potable Water)

Date of Survey : September 7, 2018

Survey Made By : /s/ Chris Ida

Date of this Report : February 16, 2019

Report Made By : /s/ Chris Ida

Reviewed By: Date:

District Ranger

Recreation Staff

Forest Engineer

PART III

ITEM NO. PAGE

PART III - FIELD DATA

IIIA. Site Identification W-29 IIIB. System Description W-29 IIIC. Attachments W-30

W- 29

REPORT OUTLINE

PART III – FIELD DATA

A. Site Identification

1. Forest: Arapaho and Roosevelt National Forest and

Pawnee National Grassland

2. Ranger District: Boulder Ranger District

3. Water System Identification Number: None (Hauled Potable Water)

4. Type of Sites Served:

(Special Use, Admin., Recreation, Other) Administrative

5. Maximum Number of Persons using System per Day: (Persons/Day) 26 Persons at One Time

6. How many days are the persons in number 5 actually using the system: 365 Days

7. Use Period: January 1 to December 31 (mm/dd)

B. System Description

The water system consists of two underground fiberglass water storage tank (2000 gallon and 3000 gallon) with a submersible pump. Storage tanks are equiped with a tank daylight drain, manway access, filler cap, and low level switch/light. Potable water is hauled from a local distributor. Water source is the City of Boulder municiple water system. Supplier operates under the Boulder County Health regulations which include monthly bacteriological testing. Water is pumped under ground to the second floor of the office in the south mechanical room. Equipment in the utility room consist of a pump disconnect, pressure tank, and pressure switch. There are no filtration or disinfection units for the water system. Points of use include lavatories, water closets, kitchen sinks, mop sink, shower, and exterior building hose bibbs.

W- 30

Boulder Ranger District Main Office – Front View

Boulder Ranger District Main Office – 3000 Gallon Underground Storage Tank

W- 31

Boulder Ranger District Main Office – 2000 Gallon Underground Storage Tank

Boulder Ranger District Main Office – South Mechanical Room Plumbing

W- 32

W- 33

Boulder Ranger District Main Office – Public Mens Bathroom

Boulder Ranger District Main Office – Public Womens Bathroom

W- 34

Boulder Ranger District Main Office – Employees Mens Bathroom

Boulder Ranger District Main Office – Employees Mens Shower

W- 35

Boulder Ranger District Main Office – Employees Womens Bathroom

Boulder Ranger District Main Office – Employees Womens Shower

W- 36

Boulder Ranger District Main Office – Public Water Fountains

Boulder Ranger District Main Office – Employees Water Fountains

W- 37

Boulder Ranger District Main Office – Conference Room Sink

Boulder Ranger District Main Office – Outdoor Faucet (Typical)

W- 38

Boulder Ranger District Extension Office – Front View

Boulder Ranger District Extension Office – Employees Mens Bathroom

W- 39

Boulder Ranger District Extension Office – Employees Womens Bathroom

Boulder Ranger District Extension Office – Employee Breakroom Sink

W- 40

Boulder Ranger District Extension Office – Utility Room Sink

Boulder Ranger District Water System – Site Plan