Ex._B_-_Wastewater_Sanitary_Survey_Form_12.11.18.docx

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Sanitary Surveys for Tribal Waste Water
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75H70319Q00013
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WASTEWATER SANITARY SURVEY FORM - INVENTORY

SYSTEM ORGANIZATION:
SYSTEM NAME:
Survey Date:
System Representative:
Survey Lead:
Previous Survey Date:
Survey Team:
Tribe/Reservation:
Other Representative:
SYSTEM MANAGER
LEAD SYSTEM OPERATOR
Name:
Name:
Phone:
( )
-
Fax:
( )
-
Phone:
( )
-
Fax:
( )
-
Email:
Email:

WASTEWATER DEPARTMENT

Department Address and Contact Information:
Description of Service Area:
Street:
City:
State:
Zip:
Phone:
( )
-
Fax:
( )
-
Email:
OPERATOR OF SYSTEM
OPERATOR OF SYSTEM
Name:
Name:
Phone:
( )
-
Fax:
( )
-
Phone:
( )
-
Fax:
( )
-
Certified Operator?|_| Yes|_| No|_| Not required
Certified Operator?|_| Yes|_| No|_| Not required
Treatment Certification Level
Treatment Certification date
Treatment Certification Level
Treatment Certification date
Treatment Certification Authority
Treatment Certification #
Treatment Certification Authority
Treatment Certification #
|_| CA WRCB
|_| ITCA
|_| CA DHS
|_| ITCA

|_| Other

|_| Other

Copy of Certificate(s)?|_| Yes|_| No
Copy of Certificate(s)?|_| Yes|_| No

OWNER TYPE

|_|1Federal Government|_|4Local Government Authority, Commission, District, Municipality, City, etc.
|_|2Mixed Public/Private|_|5Private Subdivision, Investor, Trust, Cooperative, Water Association, etc.
|_|3State Government|_|6Native American
SYSTEM STATUS
WATER SYSTEM CLASS

|_| A = Active |_| P = Pending (Add New System) |_| I = Inactive |_| C = Community |_| NTNC = Non-Transient Non-Community |_| NC = Transient NonCommunity

CUSTOMER INFORMATION

RESIDENTIAL
COMMERCIAL
Bill Collection Rate
%
%

Rates/Rate Structure Description:

Population:
Resident:
Transient:
Non-Transient:
Number of Connections:
Homes
Buildings
Number of Effluent Connections:
Homes
Buildings
% of Metered Water:
%
%

Average Wastewater Quantities:

Circle One

Circle One

Measured?
Daily
gpd
MGD
gpd
MGD
Estimated?
Annual
gpd
MGD
gpd
MGD

Maximum Design Wastewater Capacity:

Circle One

Circle One

Daily
gpd
MGD
gpd
MGD
Annual
gpd
MGD
gpd
MGD
List Major Businesses:

CALIFORNIA AREA INDIAN HEALTH SERVICE

WORKING DRAFT – DECEMBER 2018PAGE 7
WASTEWATER SANITARY SURVEY FORM – INVENTORY (CONTINUED)
SERVICE AREA CHARACTERISTICS LIST
PERSONNEL/EQUIPMENT INVENTORY
|_|
Houses
|_|
Casino
Number of Staff
Number of Specified Facilities
|_|
Apartments
|_|
Bar
Full-Time:
Manholes:
Septic Tanks:
|_|
Permanent Mobile Homes/RV
|_|
Restaurant
Part-Time:
Lift Stations:
WWTPs:
|_|
Transient Mobile Homes/RV
|_|
Shopping Center/Strip Mall
Vehicles/Machinery
|_|
Vacation/Seasonal Homes
|_|
Highway Rest Area
Quantity:
Type/Description:
|_|
Medical Facility/Clinic
|_|
Service/Gas Station
|_|
Pharmacy
|_|
Auto Repair
|_|
Government/Tribal Building
|_|
Hotel/Motel
|_|
Contractor Storage
|_|
Industry
|_|
Sanitary Improvement District
|_|
Agriculture
TREATMENT REQUIREMENTS
|_|
Day Care Center
|_|
Recreation Area
NPDES/UIC:
|_| Yes
|_| No
Permit #:
|_|
Head Start
|_|
Scrap Metal Recycle
Dates Active:
From
To
|_|
Elementary/High School
|_|
Other:
CONSECUTIVE SYSTEM INFORMATION
|_|
Summer Camp
|_|
Other:
Treatment Purchased From:
|_|
College/University
|_|
Other:
Treatment Provided For:
WASTEWATER CONSTITUENT (Typically Provided by Tribe, if required)
DATE INSTALLED (Actual or Approximate)
Sample Name
Sample Date:
Collection System:
Lift Station __________:
Lift Station __________:
Lift Station __________:
Treatment System:
Lagoon:
Disposal Field:
Other ______________:
Other ______________:
Other ______________:

Location where sample was taken:

Latitude
Longitude
Results (include units):
BOD:
TSS:
Fecal Coliform:
Phosphorus:
pH:
Oil/Grease:
Lab:
Other:

Comments/Maps:

WASTEWATER SANITARY SURVEY FORM – SEWER & LIFT STATION

Station Name/ID
Pump Activation:
Number of Pumps
Capacity gpm
Type:
Make/Model:
HP:
Amperage:
Voltage:
Date Installed:
Daily Run Time: hrs
Pump Counter Read: hrs

Auxiliary Power Type:

Average Number of Pump Starts: /day

Pump Controls have: |_| Float Switch |_| Run Hour Meter |_| Pump Protector |_| Lead/Lag |_| Manual |_| Sequencer |_| Other

SEWERS & FORCEMAINS
LIFT STATION (CONTINUED)
YesNoUnkN/A
1)Manhole covers are in good condition with good fit.|_||_||_||_|
2)Flushing frequency and records are satisfactory.|_||_||_||_|
3)Surface erosion is not evident around manholes and
over the areas where sewer lines are in use.|_||_||_||_|
4)Manholes and sewers are entered using the
precautions cited by OSHA.|_||_||_||_|
5)Interior of manholes are free of debris accumulation.|_||_||_||_|
6)Interior of manholes shows no evidence of inflow or
infiltration.|_||_||_||_|
7)Forcemain valves are exercised regularly.|_||_||_||_|
8)Are check valves, isolation valves and meters
maintained and operating properly?|_||_||_||_|
9)As-Builts are available and up-to-date|_||_||_||_|
a)Feet of mains?
b)Condition of mains?
c)Pipe Diameters inch
d)Forcemain Pressure Range: psi
e)Number of leaks repaired annually
YesNoUnkN/A
6)Over-all cleanliness of the wet-well is satisfactory?|_||_||_||_|
7)Probes, floats, or transducers are functional.|_||_||_||_|
8)Access road is maintained.|_||_||_||_|
9)Lid for weather tightness is secure.|_||_||_||_|
10)Ventilation, lights, heater, and fan operate
satisfactorily.|_||_||_||_|
11)Bar screen, sump pump, gate valves, and check
valves operate properly; piping is free of leaks.|_||_||_||_|
12)Safety grating is installed under the wet well access
hatch cover|_||_||_||_|
13)Are functional pressure-gauges installed in the
valve vault?|_||_||_||_|
14)Pressure gauges can be read without entering the
valve vault.|_||_||_||_|
15)Discharge and suction pressure of pump is adequate.|_||_||_||_|
16)Is there a source of pressurized wash-down water
on site?|_||_||_||_|
17)If so, is the water source protected by an approved
air-gap or RPZ-BPA?|_||_||_||_|
18)Does the control panel activate a functional alarm
light and/or horn?|_||_||_||_|
19)Controls are functional.|_||_||_||_|
20)Does the valve vault drain back to the wet-well?|_||_||_||_|
a) If drain is present, is there a means in place to
control flow to wet-well?|_||_||_||_|
21)Building and equipment are protected from flooding.|_||_||_||_|
22)Facility meets local design standards and is
structurally sound.|_||_||_||_|
23)Equipment can be accessed and removed for
maintenance.|_||_||_||_|
24)Check valves, meters, etc. are functioning.|_||_||_||_|
25)Operation and maintenance plan has been
developed and implemented.|_||_||_||_|
26)Manuals are available.|_||_||_||_|
27)Adequate tools and spare parts are on hand.|_||_||_||_|

PUMP

1)Pump noises are not excessive.|_||_||_||_|
2)Pumps are in good condition and lubricated regularly.|_||_||_||_|

PUMP RECORDS

1)Pumping records are satisfactory|_||_||_||_|
2)Review of records reveals no problems|_||_||_||_|

LIFT STATION

1)As-built and design data available.|_||_||_||_|
2)Fence and gate with lock are sound and facilities
have adequate security protection.|_||_||_||_|
3)Oil level on compressor is correct.|_||_||_||_|
4)Pump rails are in sound condition.|_||_||_||_|
5)Cleanliness of probes, floats, or transducers is
satisfactory.|_||_||_||_|

Comments, Schematic, and/or Photo of Installation:

WASTEWATER SANITARY SURVEY FORM – LAGOON & SEPTIC SYSTEM

LAGOON
LAGOON (CONTINUED)
YesNoUnkN/A
1)Access road is in good condition.|_||_||_||_|
2)Fence is in good condition with locked gate.|_||_||_||_|
3)Fence and gate prevent unauthorized entry.|_||_||_||_|
4)Warning signage fence surrounding the pond are in
acceptable condition.|_||_||_||_|
5)Sludge depth is measured routinely.|_||_||_||_|
Current depth: ft
6)Color of wastewater doesn’t indicate a treatment
problem. List color:|_||_||_||_|
7)There is no presence of septic odors.|_||_||_||_|
8)No materials are floating on the water surface.|_||_||_||_|
9)Insect breeding is not a vector concern.|_||_||_||_|
10)Weed growth is controlled.|_||_||_||_|
11)There is adequate freeboard (>2’) provided by dike.|_||_||_||_|
12)As-built and design data (load, detention time, etc.)
for the installation are readily available.|_||_||_||_|
13)Dikes are sound, free of erosion.|_||_||_||_|
14)Dikes are free of animal burrows.|_||_||_||_|
15)Diversion structures are free of solids and other
debris.|_||_||_||_|
YesNoUnkN/A
16)Designed overflow discharge is free of blockage or
clogging|_||_||_||_|
17)Chlorinator is functioning properly and maintained;
chemicals are available and correctly stored.|_||_||_||_|
18)Mechanical aerators and valves operate properly.|_||_||_||_|

COMMUNITY SEPTIC SYSTEM

1)Ground over the disposal area shows no evidence of
surfacing sewage.|_||_||_||_|
2)Location of inlet and outlet inspection ports can be
identified.|_||_||_||_|
3)Inlets and outlets are functioning properly.|_||_||_||_|
4)Sludge and scum accumulation levels are checked
annually and are not excessive.|_||_||_||_|
5)Distribution box is free of debris and is functioning
properly.|_||_||_||_|
6)Inspection port covers are in good condition.|_||_||_||_|
7)As-built plans for the installation are readily available.|_||_||_||_|
8)Sludge pumping service is available, and tank
pumping frequency is adequate.|_||_||_||_|

Comments, Schematic, and/or Photo of Installation:

WASTEWATER SANITARY SURVEY FORM – TREATMENT

SECURITY
MECHANICAL PRIMARY TREATMENT
YesNoUnkN/A
1)Fencing is provided where necessary and all
entrances and gates are secured, allowing entrance of
authorized persons only.|_||_||_||_|
2)Signs stating hazards of the facility are posted.|_||_||_||_|
YesNoUnkN/A
1)Infiltration or inflow is not excessive.|_||_||_||_|
2)Return process streams do not contain highly toxic or
organic constituents or excessive volumes which
interfere with treatment process or cause equipment
problems.|_||_||_||_|
3)Accumulation of sludge and scum in primary clarifier
is not excessive.|_||_||_||_|
4)Skimming and settling processes of the clarifying
compartment are operating as designed.|_||_||_||_|
5)Jets are functioning properly, dispersing fine bubbles
throughout the aeration tank.|_||_||_||_|
6)Shock loadings due to seasonal variations, toxic
chemicals, industrial discharges, organic material, or
hydraulic load do not degrade the process performance
for the treatment plant.|_||_||_||_|
7)Primary treatment process is operating properly.|_||_||_||_|
8)Preliminary treatment processes (Grit removal and
screening) are properly designed and operated to
avoid wear and tear to downstream equipment.|_||_||_||_|
9)Solids are removed and placed in another treatment
process, i.e. anaerobic digester.|_||_||_||_|
10)Skimming and settling processes of the clarifying
compartment are operating as designed.|_||_||_||_|
11)Solid materials are settled out in the primary clarifier
treatment tank; baffles are in place and properly
functioning.|_||_||_||_|

EFFLUENT QUALITY

1)System has an EPA NPDES permit if effluent is
discharged to a natural body of water.|_||_||_||_|
2)Monitoring, reporting, and limitation requirements
of the NPDES permit are met.|_||_||_||_|

OPERATION & MAINTENANCE

1)An adequate number of people are employed to
effectively and efficiently operate, maintain, and
manage the facilities.|_||_||_||_|
2)Operators are trained and are deemed to have
adequate knowledge in plant operation and
maintenance, and are certified appropriately.|_||_||_||_|
3)Operation and maintenance plan has been developed
and implemented.|_||_||_||_|
4)O&M Manuals are available.|_||_||_||_|
6)Adequate tools and spare parts are on hand.|_||_||_||_|
7)Housekeeping procedures are sufficient to maintain an
uncluttered work environment and prevent equipment
failure.|_||_||_||_|
8)Monitoring results are posted and records are kept
in order.|_||_||_||_|
MECHANICAL EQUIPMENT
ADVANCED TREATMENT
1)Motor amperage readings are within manufacturer's
specifications.|_||_||_||_|
2)Bushings and bearings are not loose or noisy.|_||_||_||_|
3)Compressors are developing an adequate quantity of
air|_||_||_||_|
4)Heating, ventilation, and lighting are adequate.|_||_||_||_|
5)Motors and compressors are lubricated, operated, and
maintained according to manufacturers'
recommendations.|_||_||_||_|
6)Electrical is wired properly, and outlets are correctly
grounded.|_||_||_||_|
7)Standby or auxiliary power is available and operational.|_||_||_||_|
8)Mechanical equipment operates properly and reliably.|_||_||_||_|
1)Adequate controls are available to allow process
flexibility to optimize process performance.|_||_||_||_|
2)Changes and adjustments in process control are
recorded and flow is monitored.|_||_||_||_|
3)Disinfection equipment is operated and maintained|_||_||_||_|
properly.
4)Feed rates are proportional to the effluent flow.|_||_||_||_|
5)Contact time is sufficient to properly disinfect
the wastewater discharge.|_||_||_||_|
6)Advanced treatment processes (nitrification towers,
chemical treatment, multimedia filters) are appropriate
to upgrade water quality to meet specific effluent limb
beyond the capacity of conventional primary and
secondary treatment.|_||_||_||_|
7)Sludge wasting can be adequately controlled. Wasted
sludge can be sampled without extreme difficulty.|_||_||_||_|
8)The aeration basin, trickling filter, RBC, etc. provides
sufficient oxygen transfer capacity..|_||_||_||_|
9)Secondary clarifier provides for adequate
settling, bulking is limited; effluent is free of
visible solid material.|_||_||_||_|

LABORATORY

1)Laboratory equipment is calibrated as required.|_||_||_||_|
2)Contracted laboratory services are compliant
for analyzing the constituents required under the
NPDES permit.|_||_||_||_|
3)Laboratory equipment is properly providing
operational control.|_||_||_||_|
4)Laboratory equipment and facilities are in good
condition and well maintained.|_||_||_||_|
5)Monitoring and sampling equipment allows the various
process flow streams to be monitored.|_||_||_||_|
6)There is adequate space in the laboratory to perform
operational testing and performance monitoring.|_||_||_||_|
7)Clear and precise operating procedures for
autoclaves, water stills and other special pressure
equipment is posted and followed.|_||_||_||_|

SLUDGE HANDLING

1)Sludge treatment process is proper for sludge
stabilization. Operation problems such as odors and
sludge wasting are minimized.|_||_||_||_|
2)Sludge disposal is accomplished within the
requirements of the local sanitation code and EPA
sludge disposal rules.|_||_||_||_|
3)Adequate facilities and equipment exist for drying,
hauling, handling and disposing of sewage sludge.|_||_||_||_|

WASTEWATER SANITARY SURVEY FORM – ADMINISTRATION

OPERATION & MAINTENANCE
PLANT SAFETY
YesNoUnkN/A
1)Operation and maintenance manuals are complete
with formal O&M plan or program in place.|_||_||_||_|
2)Inventory tracking system (spare parts, tools, vehicles)
is utilized.|_||_||_||_|
3)Maintenance vehicles and heavy equipment
are in good condition, appropriate for their task, and
properly licensed.|_||_||_||_|
4)Staffing is adequate with job descriptions in place.|_||_||_||_|
5)Preventive maintenance plan is developed and
followed.|_||_||_||_|
6)System complies with EPA CWA monitoring and
reporting.|_||_||_||_|
YesNoUnkN/A
1)Safety shower is in place and is operable.|_||_||_||_|
2)Hazards are noted and eliminated where possible.|_||_||_||_|
3)Chemicals and reagents used are properly stored
and handled.|_||_||_||_|
4)A chemical hygiene plan has been developed as
required by OSHA regulations.|_||_||_||_|
5)Operator has been trained in safe operation and
maintenance procedures; safety manuals are on hand.|_||_||_||_|
6)Gas chlorine rooms are properly designed and
maintained with: mechanical ventilation exhausting to
unoccupied areas; low level. vents; inspection
windows; outside switches for lights and fan.|_||_||_||_|
7)Self-contained breathing apparatus is available,
in good condition, and properly stored if gas
chlorination system is used.|_||_||_||_|
8)Gas chlorine room is separate from other parts of
treatment building and is marked with hazard warning
signs.|_||_||_||_|
9)Emergency repair kits for chlorine cylinders or tanks
are on hand.|_||_||_||_|
10)All mechanical equipment is properly guarded or
screened.|_||_||_||_|
11)Work areas are well lighted and ventilated.|_||_||_||_|
12)Pipetting of samples, reagents or chemicals by
mouth is not allowed.|_||_||_||_|
13)Confined spaces are tested for explosive gases,
toxic gases, and oxygen deficiency before entering.|_||_||_||_|
14)Confined spaces are ventilated with mechanical fans
prior to entering and continuously during work
procedures.|_||_||_||_|
15)Guardrails are provided at all elevated walkways and
work areas around or on tanks, basins, or structures.|_||_||_||_|
16)Fire protection is provided. Type ABC extinguishers
are available for use in the plant and laboratory.|_||_||_||_|
17)Safety goggles are worn in the laboratory. Contact
lenses are restricted from being worn in the laboratory.|_||_||_||_|
18)Potable water system is protected by an approved
backflow prevention device.|_||_||_||_|
19)Formal written safety program is in place.|_||_||_||_|

RECORDS

1)New connections and total connections are recorded.|_||_||_||_|
2)The volume of wastewater treated on a daily, weekly,
monthly, and annual basis is recorded and maintained.|_||_||_||_|
3)Records of influent and effluent quality conditions are
maintained.|_||_||_||_|
4)Pump meter readings are recorded on a timely basis.|_||_||_||_|
5)System as-built drawings are complete and available.|_||_||_||_|
6)As-built drawings are updated as facilities are changed
or modified.|_||_||_||_|
7)Records of follow-up action for samples, when
indicated, are adequate.|_||_||_||_|

MANAGEMENT

1)Utility ordinance is adopted and enforced.|_||_||_||_|
2)Annual operating budget is prepared and covers staff,
training, small asset replacement and emergencies.|_||_||_||_|
3)Capital improvement plan or master plan is developed.|_||_||_||_|
4)Small asset replacement plan is developed.|_||_||_||_|
5)Written training plan is in place.|_||_||_||_|

EMERGENCY RESPONSE

1)There is a plan for emergency operations (natural
disasters, power outages, pump failures, surfacing
wastewater, etc.).|_||_||_||_|
2)There are back-up sources available (power source,
portable generators, pumps, motors, pump trucks, or
neighboring resources that could be used, etc.).|_||_||_||_|

Comments

WASTEWATER SANITARY SURVEY FORM – COMMENTS, MAPS, AND PHOTOS

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