Attachment 3 - Operator Monthly Inspection Form.pdf

Certified Operator Monthly Inspection Form For use by Grade 1 or Grade 2 water treatment plants or distribution systems that produce and distribute groundwater

1. General Public Water System (PWS) Information:

PWS Name: _________________________________ PWS ID Number: AZ04 -____________

PWS Type: CWS NTNCWS TNCWS Population Served: _______________ PWS Source Types: Groundwater Surface Water GUDI

Purchased Ground Water Purchased Surface Water Certified Operator: ___________________________ Operator ID: OP___________________

Grade: _____________________________________ Expiration Date: __________________ E-Mail Address: _____________________________ Phone Number: ___________________

2. Inspection Inspection Date: ______________ Arrival Time: __________ Departure Time: __________ Person Conducting Inspection: ________________________________________________________ Owner/Responsible Party: __________________________ Present at Inspection Y N

Well Head: Yes No N/A Comments

Does the well site have a building or a security fence that is properly locked and secured?

Is the area around the well properly graded for drainage and is the site clean?

Does the well slab direct water away from the well?

Is the slab free of cracks or defects?

Is the well sanitary seal intact? ☐ ☐ ☐

Is there a well vent installed and is the vent protected with a #16 non corrodible mesh screen?

Is the well pressure relief valve operational? ☐ ☐ ☐

Does the well have a raw water sampling tap installed prior to treatment or disinfection?

Water Storage Tanks Yes No N/A Are the storage tank bedding ring and foundation intact?

Is the storage tank bedding ring free of weeds and vegetation?

Does the overflow pipe terminate at least two feet above erosion control (concrete slab, riprap, etc.)?

Does the overflow pipe have a working flap gate or is it protected with a #16 non-corrodible mesh screen?

Are the vents on the storage tank protected with a #16 non-corrodible mesh screen?

Is the roof hatch sealed and locked? ☐ ☐ ☐

Comments

Certified Operator Monthly Inspection Form For use by Grade 1 or Grade 2 water treatment plants or distribution systems that produce and distribute groundwater

3. Summary of observations, recommendations and corrective actions required:

I certify that I am the person authorized to fill out this form and the information contained herein is true, accurate and complete to the best of my knowledge and belief.

Operator Signature: __________________________ Date: _____________________

Date form provided to owner or responsible party: __________________________________

Booster Pumps: Yes No N/A Comments

Pump piping is intact, corrosion free and not leaking?

Pump wiring is enclosed and conduits are not leaking?

Valves are operational? ☐ ☐ ☐

Pump exterior coatings are intact? ☐ ☐ ☐

Booster pumps condition is adequate? ☐ ☐ ☐

Disinfection Equipment: Yes No N/A Comments

Disinfectant meets the ANSI/NSF standard 60 and is labeled?

Disinfectant injection system is operational and calibrated?

Adequate back-up supply of disinfectant is available?

Test kit are available to test for Maximum Residual Disinfectant Level/ Residual Disinfectant Level?

Daily log is properly maintained? ☐ ☐ ☐

Paperwork/Reporting Requirements Yes No N/A Comments

Have monthly/quarterly sampling requirements been fulfilled?

Are all sampling/operations plans up to date and in an accessible location?