A04_SOW_Attachments_0001.pdf

Attachment A. List of Bureau of Indian Education funded schools associated to the 34 Indian Affairs Public Water Systems (PWS).

School Name Address City State Zip

Code Local POC POC Title Phone Email

Education Program Administrator (EPA)

EPA Phone EPA email

Blackfeet Boarding Dorm P.O. Box 627, 1 Dormitory Road Browning MT 59417 Daryl Croff Acting Dormitory Supervisor

406-338-7441x202 daryl.croff@bie.edu Casey Sovo 701-477- 3463x11/701-550-casey.sovo@bie.edu

Bread Springs School P.O. Box 1117 Gallup NM 87305 Betty Diana Principal 505-778-5665 Betty.Diana@bie.edu

John McIntosh 928-871-5938/928- 245-8592 john.mcintosh@bie.edu

Bug-O-Nay-Ge-Shig School 15353 Silver Eagle Drive NW Bena MN 56626 Dan McKeon Director (218) 665-3000 dan.mckeon@bugschool.k12.

mn.us

Dr. Berdina Tsosie 612-875-4985 Berdina.tsosie@bie.edu

Chemawa Indian School 3700 Chemawa Rd. NE Salem OR 97305 Amanda Ward Superintendent

(503) 399- 5721x1345 amanda.ward@bie.edu Dr. Maxine Roanhorse- DineYazhe

602-265- 1592x1865/ 602- 339-7606 maxine.roanhorse-dineyazhe@bie.edu

Chi Chil Tah/Jones Ranch Community School

P.O. Box 278 Vanderwagen NM 87326 Marlene Tsosie Principal (505) 778-5574 Marlene.Tsosie@bie.edu John McIntosh 928-871-5938/928- 245-8592 john.mcintosh@bie.edu

Ch'oosgai Community School PO Box 321 Tohatchi NM 87325 Frank Chiapetti Principal (505) 733-2700 fchiapetti@ccsbroncos.org Dr. Sharon Henderson- Singer

480-492-6559 sharon.henderson-singer@bie.edu

Crazy Horse School 245 Crazy Horse School Drive Wanblee SD 57577 Silas Blaine Superintendent 605-462-6834 silas.blaine@k12.sd.us Shilo Krolikowski 612-723-1428 Shilo.Krolikowski@bie.e du

Crow Creek Reservation High School

103 Chieftain Road Stephan SD 57346 Brian Sieh Superintendent 605-852-6251/605- 661-0313 brian.sieh@k12.sd.us Ann Longie 612-723-1438/605- 219-5655 ann.longie@bie.edu

Crow Creek Tribal Elementary School

103 Chieftain Road Stephan SD 57346 Brian Sieh Superintendent 605-852-6251/605- 661-0313 brian.sieh@k12.sd.us Ann Longie 612-723-1438/605- 219-5655 ann.longie@bie.edu

Crystal Boarding School P.O. Box 1288 Navajo NM 87328 Alberto Castruita Principal (505) 777-2385 alberto.castruita@bie.edu John McIntosh 928-871-5938/928- 245-8592 john.mcintosh@bie.edu

Dzilth-Na-O-Dith-Hle Community School (Dz)

33 Road 7585 #5003 Bloomfield NM 87413 Chystal Martinez-Tom Prinicpal (505) 960-0356 chrystal.tom@bie.edu Dr. Sharon Henderson- Singer

480-492-6559 sharon.henderson-singer@bie.edu

Flandreau Indian Boarding School

1132 North Crescent Street Flandreau SD 57028 Everall Fox Superintendent (605) 997-3773 everall.fox@bie.edu Lora Braucher 605-867-1306/605- 407-9999 lora.braucher@bie.edu

Greasewood Springs Community School

HC 58 Box 60 Ganado AZ 86505 Ms. Lucinda Godinez Principal

(928) 654-3384/928- 654-3331x0/928- 206-7444 lucinda.godinez@gscs-inc.net Dr. Sharon Henderson- Singer

480-492-6559 sharon.henderson-singer@bie.edu

Hopi Junior Senior High School Highway 264 (Behind Police Station) Keams Canyon AZ 86034 Alban Naha Acting Superintendent/JH P.

928-738-1410 ANaha@hjshs.org

Ms. Connie Albert 505-263-1859 Connie.Albert@bie.edu

Hunters Point Boarding School PO Box 99 St. Michaels AZ 86511 Julia Donald Principal (928) 871-4439 jdonald@hpbs-az.org Dr. Sharon Henderson- Singer

480-492-6559 sharon.henderson-singer@bie.edu

Kayenta Community School HC 163 Box 188 Kayenta AZ 86033 Louise Donald Principal (928) 697-3439 louise.donald@bie.edu Dr. Edie Morris 928-871-5936/928- 245-8805 edie.morris@bie.edu

Leupp Schools, Inc. HC 61 Box D Winslow AZ 86047 Emma Yazzie Principal (928) 686-6211 eyazzie@leuppschools.org Dr. Janet Slowman- Chee

928-871-5942 janet.slowmanchee@bie.

edu

Many Farms High School P.O. Box 307 Many Farms AZ 86538 Tonya Knight Principal (928) 781-6226 tonya.knight@bie.edu Dr. Walter Coulter 928-871-5972 walter.coulter@bie.edu

Ojo Encino Day School HCR 79 Box 7 Cuba NM 87013 Deloria Chapo Acting Principal (505) 731-2333 Deloria.Chapo@bie.edu Dr. Janet Slowman- Chee

928-871-5942 janet.slowmanchee@bie.

edu

Pierre Indian School Learning Center

3001 E. Sully Avenue Pierre SD 57501 Dr. Veronica Morley Superintendent (605) 224-8661 veronic.morley@k12.sd.us Dr. Berdina Tsosie 952-851-5426 Berdina.tsosie@bie.edu

Pine Springs Day School P.O. Box 4198 Houck AZ 86505 Lou Ann Jones Principal (928) 871-4311 lou.jones@bie.edu Dr. Walter Coulter 928-871-5972 walter.coulter@bie.edu

Pueblo Pintado Community School

HCR 79 Box 80 Cuba NM 87013 Ms. Irowena Whitehair Principal (505) 655-3341 irowena.whitehair@bie.edu Dr. Janet Slowman- Chee

928-871-5942 janet.slowmanchee@bie.

edu

Red Rock Day School P.O. Box 2007 Red Valley AZ 86544 Dr. Jeannie Kee-Parsons Principal (928) 653-4456 Jeannie.Keeparsons@bie.edu Dr. Walter Coulter 928-871-5972 walter.coulter@bie.edu

Rock Point Elementary School PO Box 560 Rock Point AZ 86454 Deana Dugi CEO (928) 659-4221 deana.dugi@rpcsaz.org Dr. Janet Slowman- Chee

928-871-5942 janet.slowmanchee@bie.

edu

Rock Point High School PO Box 560 Rock Point AZ 86454 Deana Dugi CEO (928) 659-4221 deana.dugi@rpcsaz.org Dr. Janet Slowman- Chee

928-871-5942 janet.slowmanchee@bie.

edu

Rocky Ridge Boarding School P.O. Box 299 Kykotsmovi AZ 86039 Veronica Klain Acting Principal 928-725-3235 Veronica.Klain@bie.edu Dr. Walter Coulter 928-871-5972 walter.coulter@bie.edu

Rough Rock Elementary School HC61 Hwy PO Box 5000-PTT Chinle AZ 86503 Ronald Thompson Principal (928) 728-3701 ronald.thompson@roughrock.

k12.az.us

Dr. Janet Slowman- Chee

928-871-5942 janet.slowmanchee@bie.

edu

Rough Rock High School HC61 Hwy PO Box 5000-PTT Chinle AZ 86503 Ronald Thompson Principal (928) 728-3701 ronald.thompson@roughrock.

k12.az.us

Dr. Janet Slowman- Chee

928-871-5942 janet.slowmanchee@bie.

edu

Second Mesa Day School 100 Loop Road Second Mesa AZ 86043 Kim Thomas Chief School Administrator

928-737-2571/928- 313-5931 Kim.thomas@secondmesa.org

Dr. Valerie Todacheene

505-263-2884 valerie.todacheene@bie.e du

Shonto Prepratory School PO Box 7900 Shonto AZ 86054 Melanie Dewakuku Principal (928) 672-3521 melanie.dewakuku@shontopre p.org

Dr. Janet Slowman- Chee

928-871-5942 janet.slowmanchee@bie.

edu

Tiis Naz Bas Community School P.O. Box 2002 Teec Nos Pos AZ 86514 Dr. Karina Roessel Principal (928) 656-3252 karina.roessel@bie.edu Dr. Walter Coulter 928-871-5972 walter.coulter@bie.edu

To' Hajiilee Day School (Canoncito)

PO Box 3438 Canoncito NM 87026 Willinda Castillo Principal (505) 908-2426 wilinda.castillo@tohajiilee.co m

Dr. Sharon Henderson- Singer

480-492-6559 sharon.henderson-singer@bie.edu

Tonalea Day School (Red Lake) P.O. Box 39 Tonelea AZ 86044 Cheryl L Kaye Principal (928) 283-6325 cheryl.kaye@bie.edu Dr. Walter Coulter 928-871-5972 walter.coulter@bie.edu

Tuba City Boarding School P.O. Box 187 Tuba City AZ 86045 Don Coffland Principal (928) 283-2330 donald.coffland@bie.edu Dr. Walter Coulter 928-871-5972 walter.coulter@bie.edu

Wide Ruins Community School PO Box 309 Chambers AZ 86502 Jeannie Lewis Principal (928) 352-3251 j.lewis@kinteelolta.org Dr. Janet Slowman- Chee

928-871-5942 janet.slowmanchee@bie.

edu

Wingate Elementary School P.O. Box 1 Wingate NM 87316 Mr. Eric North Principal (505) 488-6300 eric.north@bie.edu John McIntosh 928-871-5938/928- 245-8592 john.mcintosh@bie.edu

Wingate High School P.O. Box 2 Wingate NM 87316 Ms. Gloria Arviso Principal (505) 488-6400 gloria.arviso@bie.edu John McIntosh 928-871-5938/928- 245-8592 john.mcintosh@bie.edu

Attachment B. Template of the Executive Summary.

TITLE 1

TITLE

Author’s Names

Organization

[Recommend including a table of contents on the next page]

2 TITLE

EXECUTIVE SUMMARY

Significant Background/Observations:

[This section covers notable assessment findings in plain language and is intended for the audience of facility/school leaders. The summary should include a general statement on water quality (whether it meets EPA standards). The goal of the summary is to empower the school leader to take action. More technical information can be detailed in the critical area pages.]

Recent Inspections or Violations:

[Summarize findings from any other recent sanitary surveys or inspections conducted by a third party. Also note if there are any current regulatory violations for the system or if any violations have been identified and corrected in the past 5-10 years].

Summary of Sampling Results:

[At a minimum, the assessment will have lead and copper sampling results. Summarize any exceedances of health-based standards here. Summarize all sampling results in an easy-to-read table with sampling date, time, location, type of fixture, parameter e.g., lead, copper), result, and suspected source (if detectable).

Recommendations:

[The table of recommendations should include the following, at a minimum:]

Description Priority Estimated ROM Cost

Insert 1st recommendation. For example: Repair or replace chlorination system which is not calibrated and leading to too high or too low disinfectant levels.

High [this action is needed to prevent immediate health consequences OR to prevent catastrophic system failure]

Insert 2nd recommendation. For example: Replace well pump that is beyond recommended service life and has calcium scaling.

Medium [this action is needed to prevent long-term health consequences or system failure within 5 years]

TITLE 3

Insert 3rd recommendation. For example: Remove or replace classroom water faucet leading to elevated levels. Not often used for consumption and can be taped off.

Low [this action is part of preventive maintenance or best practices to ensure water quality and long-term system function].

Overall Priority Rating:

[Assign a High, Medium, Low priority rating for the entire system. Use the same criteria described in the “high, medium and low” descriptions in the table above. This will be somewhat subjective, but is intended to help prioritize resources for sites with the greatest risks for health consequences or system failure].

Attachment C. WQ01 – WQ07 Critical Area forms for the BIE Water System Assessment.

Bureau of Indian Education Schools Comprehensive Water System Assessment WQ01 – Drinking Water Source

Date(s) of Assessment: Maximo Asset Number(s):

Location/School:

Public Water System Number (Primary Agency):

Contractor Information

Company Name: Phone Number:

Onsite Personnel: Email:

Critical Area – WQ01 – Drinking Water Source

Critical Elements (a – g)

Description/Specifications Condition Assessment (Identify root cause if possible)

Maximo Priority

(1 Emergency

- 5 Lowest)

Corrective Action ROM (Estimate)

a) Water Source

i. Type (groundwater, ground water under direct influence, surface, truck, etc.):

b) Geography

i. Surrounding geography of the water source/predominant land use (such as agriculture, urban, suburban, etc.)

Description/Specifications Condition Assessment (Identify root cause if possible)

Maximo Priority

(1 Emergency

- 5 Lowest)

Corrective Action ROM (Estimate)

c) Vertical Well

i. Owner and Location (Decimal Degree

(DD) coordinates):

ii. Service Company/Agency Information for Well (Name, contact, address, phone):

iii. Drilling Company (Name, contact, address, phone):

iv. As Built:

1. Attach Diagrams/Plans/Maps as Needed:

2. Geologic Information:

Description/Specifications Condition Assessment (Identify root cause if possible)

Maximo Priority

(1 Emergency

- 5 Lowest)

Corrective Action ROM (Estimate)

3. Type of Casing Used/ Screened Interval:

4. Size and Type of Screen Used:

v. Well Capabilities

1. Capabilities/Yield (GPM):

2. Static Water Table (include historical levels where available):

Date last checked:

d) Well Assessment

i. Identify the Potential Point Sources for

Well Contamination (i.e., Discharge pipes, factories, etc.):

ii. Identify Potential Nonpoint Sources for Well Contamination (i.e., agriculture operations, etc.):

possible)

Maximo Priority

(1 Emergency

- 5 Lowest)

Corrective Action ROM (Estimate)

iii. Visual In-Person Sanitation Inspection of the Well.

1. Sanitary Seals:

2. Well Cap Screen:

3. Signs of Compromised Casing:

4. Well Pump and Controls (pump manufacture., manufacture. date, and pump model number):

5. Service Company /Agency Information for Pumps and Controls (Name, contact, possible)

Maximo Priority

(1 Emergency

- 5 Lowest)

Corrective Action ROM (Estimate)

iv. Review Well Construction Relative to Federal (State, Tribal) standards:

v. Evaluation of Water Source to Identify Potential Vulnerability (i.e., lower water level, security):

e) Surface Water Intake Structures:

i. Owner and Location (Decimal Degree

(DD) coordinates):

ii. Service Company /Agency Information for Surface Water Intake Structures (Name, contact, address, phone):

iii. Geography of the Surrounding Area (such as agriculture, urban, suburban, etc.)

iv. Capabilities/Yield (GPM):

possible)

Maximo Priority

(1 Emergency

- 5 Lowest)

Corrective Action ROM (Estimate)

v. Identify the Potential point sources for well contamination (i.e., Discharge pipes, factories, etc.):

vi. Identify potential nonpoint sources for well contamination (i.e., agriculture operations, etc.):

vii. Review construction relative to federal (state, tribal) standards for intake valves:

viii. Evaluation of intake pipes:

1. Type of pipes (Material Type (PVC, galvanized steel, etc.) :

2. Condition of pipes:

possible)

Maximo Priority

(1 Emergency

- 5 Lowest)

Corrective Action ROM (Estimate)

ix. Pump and Controls (pump mfg., mfg.

date, and pump model number):

x. Service Company /Agency Information for pumps and controls (Name, contact,

xi. Evaluation of water source to identify potential vulnerability (i.e., lower water

f) Other Drinking Water Sources (i.e., potable water filling stations, etc.)

i. Type/Method of delivery (water trucks, bottled water, etc.):

ii. Company/Agency Information (Name, contact, address, phone):

possible)

Maximo Priority

(1 Emergency

- 5 Lowest)

Corrective Action ROM (Estimate)

iii. Water Quality Assurance Process (i.e., NPDWR compliance):

g) Additional Helpful Information

i. Provide additional helpful information to ensure water safety and reliability (history of repairs/issues, etc.):

Attach pictures as required in Statement of Work Attach maps as needed.

WQ02 – Transmission/Distribution

Date(s) of Assessment: Maximo Asset Number(s):

Location/School:

Public Water System Number (Primary Agency):

Contractor Information

Company Name: Phone Number:

Onsite Personnel: Email:

Critical Area – WQ02 – Transmission/Distribution

Critical Elements (a – c) – Generate this form for all pipes identified.

possible)

Maximo Priority

(1 Emergency

- 5 Lowest)

Corrective Action ROM (Estimate)

a) Pipe

i. Line Type (main, service, etc.):

ii. Material Type (PVC, galvanized steel, etc.):

iii. Size (diameter, in addition, determine adequacy for both typical use and fire suppression):

possible)

Maximo Priority

(1 Emergency

- 5 Lowest)

Corrective Action ROM (Estimate)

iv. Length:

v. Age of Pipe:

vi. Location:

1. Street or other identifiable location (Decimal Degree (DD) coordinates):

2. Maps or other images:

3. As-built (layout):

vi. Service Company/Agency Information for pipes (Name, contact, address, phone):

b) Valves

i. Type (air-relief, blow-off, backflow, etc.):

possible)

Maximo Priority

(1 Emergency

- 5 Lowest)

Corrective Action ROM

ii. Size (in addition, determine adequacy):

iii. Location:

iv. Number of valves:

v. Manufacturer and date of mfg.:

vi. Maintenance and Inspection Periodicities:

vii. Service Company/Agency Information for valves (Name, contact, address, phone):

c) Additional Helpful Information ensure treatment system safety and reliability (history of repairs/issues, etc.):

WQ03 – Storage

Critical Area – WQ03 – Drinking Water Storage

Critical Elements (a – e) possible)

Maximo Priority

(1 Emergency

- 5 Lowest)

Corrective Action ROM (Estimate)

a) Tanks

i. Type (concrete, metal, ground, elevated,

ii. Size (capacity, adequate for intended use?):

iii. Height:

possible)

Maximo Priority

(1 Emergency

- 5 Lowest)

Corrective Action ROM

iv. Manufacturer:

v. Water Type (raw water, treated, etc.):

vi. Age:

vii. Pressure:

viii. Pumping System:

ix. Foundation Design (material, stability, erosion issues, etc.):

x. Service Company/Agency Information for storage (Name, contact, address, phone):

possible)

Maximo Priority

(1 Emergency

- 5 Lowest)

Corrective Action ROM (Estimate)

b) Location

i. Location (Decimal Degree (DD) coordinates):

ii. Availability of maps or other images of the potential layout for storage:

c) Corrosion Protection

i. Type:

d) Maintenance

i. Service Company/Agency Information for maintenance (Name, contact, address,

ii. Type of test:

Date:

iii. Cleaning:

possible)

Maximo Priority

(1 Emergency

- 5 Lowest)

Corrective Action ROM (Estimate)

iv. Surface Recoating:

v. Health and Safety System Compliance Inspection:

vi. Evaluation of water storage to identify potential vulnerability (i.e., low water

vii. Identify concerns to water quality from storage:

viii. Tank Mixing System (if installed):

e) Additional Helpful Information

i. Provide Additional Helpful Information to

Ensure Well Water Safety and Reliability (History of repairs/issues, etc.):

WQ04 – Treatment System

Critical Area – WQ04 – Treatment System

Critical Elements – (a – h) – Reproduce this form for different methods or electrical systems.

possible)

Maximo Priority

(1 Emergency - 5 Lowest)

Corrective Action ROM (Estimate)

a) Primary Treatment

i. Type (bar screens, grit chamber, primary clarifier, etc.):

ii. Manufacturer (if applicable):

Date of Construction:

possible)

Maximo Priority

(1 Emergency - 5 Lowest)

Corrective Action ROM (Estimate)

iii. As Built:

iv. Service Company/Agency Information for treatment system (Name, contact,

b) Secondary Treatment

i. Type (filtration, activated sludge, reverse osmosis, etc.):

iii. Service Company/Agency Information

c) Tertiary Treatment

i. Type (polishing, fluoridation, softening, possible)

Maximo Priority

(1 Emergency - 5 Lowest)

Corrective Action ROM

d) Disinfection

i. Type (Chlorination, gas, sodium hypochlorite, ozone, UV, etc.):

ii. Manufacturer:

Description/Specifications Condition Assessment (Identify root cause if possible)

Maximo Priority

(1 Emergency - 5 Lowest)

Corrective Action ROM (Estimate)

e) Downstream Additional Treatment

i. Hot Water Heaters (scale build up, valves, corrosion, service life, etc.):

1. Manufacturer:

Date:

2. Service Company/Agency Information for treatment system (Name, contact, address, phone):

ii. Point of use filters (filter change date, contaminant targeted, reverse osmosis,

1. Manufacturer:

Description/Specifications Condition Assessment (Identify root cause if possible)

Maximo Priority

(1 Emergency - 5 Lowest)

Corrective Action ROM (Estimate)

2. Service Company/Agency Information for treatment system (Name, contact, address, phone):

f) Electrical Control Systems

i. Location:

1. Street or other identifiable location (Decimal Degree (DD) coordinates):

ii. Type (SCADA systems, VFD Motor, electrical control systems, computers, sensors, etc.):

iii. Manufacturer:

Installation Date:

possible)

Maximo Priority

(1 Emergency - 5 Lowest)

Corrective Action ROM

iv. Model Number:

v. Number of Units:

vi. Size of Units (horsepower, voltage, etc.):

vii. Alarms/indicator lights, etc.:

viii. Service Company/Agency Information for electrical systems (Name, contact,

g) Building Conditions

i. Structure Use:

ii. Type (permanent shed, manufactured home, etc.):

Description/Specifications Condition Assessment (Identify root cause if possible)

Maximo Priority

(1 Emergency - 5 Lowest)

Corrective Action ROM (Estimate)

iii. Location

1. Street or other identifiable location (Decimal Degree (DD) coordinates):

2. Maps or other images:

3. Service Company/Agency Information for electrical systems (Name, contact, address, phone):

iv. Health and Safety issues (chemical storage, pest management, leaks, etc.):

Description/Specifications Condition Assessment (Identify root cause if possible)

Maximo Priority

(1 Emergency - 5 Lowest)

Corrective Action ROM (Estimate)

h) Additional Helpful Information

i. Provide additional helpful information to ensure treatment system safety and reliability (history of repairs/issues, etc.):

WQ05 – Operations

Critical Area – WQ05 – Operations

Critical Elements – (a – e) possible)

Maximo Priority (1 Emergency -

5 Lowest)

Corrective Action ROM (Estimate)

a) Staff

i. Principal/Authorized Representative:

1. Contact Information (address, email, telephone number):

ii. Facility Manager/Water Quality

Specialist:

possible)

Maximo Priority (1 Emergency -

5 Lowest)

Corrective Action ROM (Estimate) telephone number):

2. Water Quality Certification (level, based on federal, state, tribal regulations):

3. Experience (short description, years,

a. Water Quality Treatment:

b. Water Testing:

c. Reporting:

iii. Additional School Support Staff:

Telephone Number):

possible)

Maximo Priority (1 Emergency -

5 Lowest)

Corrective Action ROM (Estimate)

2. Experience/Training (short description, years, water certification level, etc.):

iv. Additional Support (Contractor, Federal

Assistance, Tribe, Tribal Agency, etc.):

1. Service Company/Agency Information for Operations (Name, contact, address, phone):

b) Demographics

i. Number of Students:

ii. Number of Staff:

c) Finance

i. Operations and Maintenance Budget:

possible)

Maximo Priority (1 Emergency -

5 Lowest)

Corrective Action ROM

ii. Technical Training Budget:

d) Records and Documentation

i. Location of Records:

ii. Records (water sampling/testing, treatment records, etc.):

iii. Records/Equipment Management (plans, tracking systems, storage, etc.):

iv. Latest Consumer Confidence Report:

v. Sanitary Survey:

vi. In-House Monitoring (adequate monitoring, SOPs, QA/QC, etc.):

possible)

Maximo Priority (1 Emergency -

5 Lowest)

Corrective Action ROM (Estimate)

vii. PFAS Sampling Records:

viii. Preventive Maintenance Records/Routine Maintenance Schedules:

ix. Construction Modifications (well repair,

x. Safety Data Sheets:

xi. Water Consumption Estimates:

1. Historical Consumption Records:

2. Current and Estimated Consumption Rates:

possible)

Maximo Priority (1 Emergency -

5 Lowest)

Corrective Action ROM (Estimate)

xii. Notice of Violations (NOVs) for Safe Drinking Water Act Over the Past 3 years:

xiii. Record of Violations of National Pollutant Discharge Elimination System

(NPDES):

xiv. Sustainability or Innovative Technology Practices or Plans (green purchasing, water optimization, energy audits, etc.):

e) Additional Useful Information ensure operational safety and reliability (history of issues, etc.):

WQ06 – Wastewater System

Date(s) of Assessment: Maximo Asset Number(s):

Location/School:

Public Water System Number (Primary Agency) and/or National Pollution Discharge Elimination System Number(s):

Contractor Information

Company Name: Phone Number:

Onsite Personnel: Email:

Critical Area – WQ06 – Wastewater System

Critical Elements (a – d) – Reproduce this form for different collection systems.

Description/Specifications Condition Assessment (Identify root cause if possible)

Maximo Priority

(1 Emergency - 5 Lowest)

Corrective Action ROM (Estimate)

a) Collection System Method

i. Material Pipe Type (PVC, galvanized steel, ductile iron, etc.):

ii. Size (diameter, in addition, determine adequacy):

possible)

Maximo Priority

(1 Emergency - 5 Lowest)

Corrective Action ROM

iii. Length:

iv. Age of pipes:

v. Location:

2. Maps or other images:

3. As-Built (layout):

vi. Service Company/Agency Information for collection system (Name, contact, Description/Specifications Condition Assessment (Identify root cause if possible)

Maximo Priority

(1 Emergency - 5 Lowest)

Corrective Action ROM (Estimate)

vii. Lift Stations (if applicable):

1. Pump Type:

2. Manufacturer:

Date:

3. Model Number:

4. Service Company/Agency Information for lift stations (Name, contact, address, phone):

b) Wastewater Treatment System

i. Collection Type (Combined or Separate

Sanitary sewers):

Description/Specifications Condition Assessment (Identify root cause if possible)

Maximo Priority

(1 Emergency - 5 Lowest)

Corrective Action ROM (Estimate)

ii. Wastewater System Type (On-site Sewage Lagoon, Septic, local off-site utilities):

iii. Condition of On-site Wastewater System:

iv. Wastewater Treatment Method (tablets, chlorine, activated sludge, sequence batch reactors, UV, etc.):

1. Storage:

v. Location:

Description/Specifications Condition Assessment (Identify root cause if possible)

Maximo Priority

(1 Emergency - 5 Lowest)

Corrective Action ROM (Estimate)

2. Maps or other images:

3. As-Built (layout):

4. Distance from potable water source

(NPDES):

vi. Service Company/Agency Information for On-site Wastewater System (Name, contact, address, phone):

c) Contingency for Emergencies

i. Emergency Response Plan (i.e., accidental wastewater discharge, etc.):

ii. Mitigation Actions (procedures, equipment, supplies, etc.)

possible)

Maximo Priority

(1 Emergency - 5 Lowest)

Corrective Action ROM (Estimate)

d) Additional Helpful Information

i. Provide additional helpful information to ensure wastewater treatment system safety and reliability (spill kits, history of repairs/issues, blockage, etc.):

WQ07 – Water Fire Suppression and Emergency Response

Critical Area – WQ07 – Water Fire Suppression and Emergency Response

Critical Elements (a – d) possible)

Maximo Priority

(1 Emergency

– 5 Lowest)

Corrective Action ROM (Estimate)

a) Water Fire Suppression Storage

i. Flow Test:

ii. Water type (raw, treated, etc.):

iii. Cross connections with potable water (i.e. backflow prevention):

possible)

Maximo Priority

(1 Emergency

– 5 Lowest)

Corrective Action ROM (Estimate)

iv. Flow Alarm Test:

v. Service Company/Agency Information for hydrants/pipes (Name, contact,

b) Fire Hydrants

i. Type:

ii. Size of pipes (in addition, determine adequacy):

iii. Quantity:

iv. Age:

possible)

Maximo Priority

(1 Emergency

– 5 Lowest)

Corrective Action ROM (Estimate)

v. Service Company/Agency Information for hydrants/pipes (Name, contact, address,

c) Records and Documentation

i. Inspection:

ii. Tests:

iii. Maintenance:

iv. Preventive Maintenance Records/Routine Maintenance Schedules:

d) Contingency for Emergencies

i. Alternative water supply options:

possible)

Maximo Priority

(1 Emergency

– 5 Lowest)

Corrective Action ROM (Estimate)

ii. Availability of alternate water supply (duration/time):

iii. Emergency Identification/Notification Procedures (Federal, State, local, etc.):

iv. Critical Response Personnel:

v. Mitigation and Conservation Plan:

e) Additional Helpful Information ensure fire suppression safety and reliability (history of repairs/issues, etc.):

Attachment D. Photographic Log – to be used with WQ-01 – WQ-07.

Date(s) of Assessment:

Public Water System Number (Primary Agency):

Contractor Information

Company Name: Phone Number:

Onsite Personnel: Email:

Photo Log Date Photo

Number Description

Example:

MM/DD/YYYY

Crit. Area# - Photo #:

WQ01-01

Description:

Wellhead with all openings sealed, conduit box sealed, etc.