Performance_Work_Statement_Draft.pdf

10/15/2015

DRAFT

PERFORMANCE

WORK

STATEMENT

Tribal Drinking Water System Technical

Assistance and Capacity Development for

Tribal Water Systems in Wisconsin and

Minnesota

Water Division, Ground Water Drinking Water

Branch, Direct Implementation

U.S. ENVIRONMENTAL PROTECTION AGENCY, REGION 5

Table of Contents Part 1

Acronyms:

Part 2

General Information

Part 3

Contractor Furnished Items, Services, and Responsibilities

Part 4

Specific Tasks

Part 5

Reference Materials

Part 6

Deliverables Schedule

Part 7

Quality Assurance Surveillance Plan

APPENDIX A

Qualifications

APPENDIX B

Project Title - Cross Connection Control Programs

APPENDIX C

Water System Inventory Form

APPENDIX D

Sanitary Survey Form Template

APPENDIX E

Sample Water Loss Tracking

APPENDIX F

Energy Checklist Outline

APPENDIX G

Active Tribal Water Systems

APPENDIX H

Capacity Development Tracking Sheet

APPENDIX I

CD Snapshots (Annual Data Ending March 2015)

Part 1

Acronyms:

CCE Contracting Center of Excellence

CD Capacity Development

CFR Code of Federal Regulations

CONUS Continental United States (excludes Alaska and Hawaii)

COR Contracting Officer Representative

DA Department of the Army

DD250 Department of Defense Form 250 (Receiving Report)

DD254 Department of Defense Contract Security Requirement List

DFARS Defense Federal Acquisition Regulation Supplement

DOD Department of Defense

DWIG Drinking Water Infrastructure Grant

DWIG-TSA Drinking Water Infrastructure Grant-Tribal Set Aside

DWS Drinking Water System ‘same as PWS in this document’

EPA United Stated Environmental Protection Agency Region 5

FAR Federal Acquisition Regulation

GWUDI Groundwater Under the Direct Influence of Surface Water

HIPAA Health Insurance Portability and Accountability Act of 1996

IHS Indian Health Service

KO Contracting Officer

OCI Organizational Conflict of Interest

ODC Other Direct Costs

PIPO Phase In/Phase Out

POC Point of Contact

PWS Public Water System (PWS)

QA Quality Assurance

QAP Quality Assurance Program

QASP Quality Assurance Surveillance Plan

QC Quality Control

QCP Quality Control Program

RTCR Revised Total Coliform Rule

TE Technical Exhibit

Part 2

General Information

2 GENERAL: The non-personnel services provide technical assistance and capacity development services for Tribal public water systems in Wisconsin and Minnesota. The contractor shall work with the tribes to develop the necessary technical, managerial, and financial capacity for tribal Public Water System (PWS) utility organizations located within the State of Wisconsin and Minnesota to achieve compliance with the Safe Drinking Water

Act. The Government shall not exercise any supervision or control over subcontracted service providers performing the services herein. Such subcontracted service providers shall be accountable solely to the Contractor who, in turn is responsible to the Government.

2.1 Description of Services/Introduction: Non-personal services necessary to perform technical assistance and capacity development services for Tribal public water systems to

11 tribes in Wisconsin and 11 tribes in Minnesota as defined in this Performance Work

Statement.

2.2 Background: The Safe Drinking Water Act (Section 1452(a) and (i) and Section 1420) encourages PWS regulatory agencies to ensure that all new community or non-transient, non-community water systems commencing operation after October 1, 1999, demonstrate technical, managerial, and financial capacity with respect to the national primary drinking water regulations. The tribal PWS regulatory program in EPA Region 5 is implemented by the Water Division.

2.3 Since the Agency is responsible for the direct implementation of the Public Water Supply

Supervision Program, it may be necessary for the Contractor to provide personnel who can make site visits to the various PWSs or to conduct meetings with Wisconsin and

Minnesota’s state and local environmental or public health officials. The work may include technical assistance visits to correct a number of compliance issues that the PWSs have identified. Other types of technical assistance may include, but not limited to, assisting the tribes with capacity development, mapping projects, and safety plans.

2.4 Scope: The Contractor shall provide all labor, supervision, supplies, materials and equipment to provide technical assistance and capacity development services to the eleven tribes located in the State of Wisconsin and in the State of Minnesota. The

Contractor shall provide technical assistance by working with the tribes to bring the

Drinking Water System (DWS) in compliance with the Safe Drinking Water Act. The

EPA Contracting Officer’s Representative (COR) will provide technical clarification to the Contractor, on work to be performed, in accordance with this performance work statement.

2.5 The Contractor may provide opinions, recommendations, and/or suggestions to the

Agency for consideration. The Agency will make all final decisions related to opinions, recommendations, and/or suggestions, as well as work products subject to Agency review and approval. The Contractor shall not interpret Agency policy or regulations.

2.6 General Assignment Information:

2.6.1 Quality Control and Assurance Plan criteria: The Contractor shall maintain an effective quality control program to ensure services are performed in accordance with this Performance Work Statement. The Contractor shall develop and implement procedures to identify, prevent, and ensure non-recurrence of defective services. The Contractor’s quality control program is the means by which he assures himself that his work complies with the requirement of the contract. This quality control program can be submitted with the Contractor’s proposal. The government shall evaluate the Contractor’s performance under this contract in accordance with the Quality Assurance Surveillance Plan (QASP). This plan is primarily focused on what the Government must do to ensure that the Contractor has performed in accordance with the performance standards. It defines the performance standards, how the performance standards will be applied, the frequency of surveillance as applicable, and the minimum acceptable defect rate(s).

2.6.2 Recognized Holidays:

Month Day Holiday

January 1 New Year’s Day

January Third Monday Martin Luther King Day

February Third Monday Washington’s Birthday

May Last Monday Memorial Day

July 4 Independence Day

September First Monday Labor Day

October Second Monday Columbus Day

November 11 Veterans Day

November Fourth Thursday Thanksgiving Day

December 25 Christmas Day

2.6.3 Hours of Operation: The Contractor is responsible for conducting business during hours that are within the guidelines of its’ organization or other hours that the

Contractor has coordinated with the public water system(s) or with the EPA COR.

The contractor shall immediately notify by phone the EPA COR for assistance requests received from the tribes or Indian Health Service (IHS) after work hours and/or weekends.

2.6.4 Place of Performance: The work to be performed under this contract will be at a contractor facility and at a Wisconsin or Minnesota tribal Drinking Water facility.

2.6.5 Post Award Conference/Periodic Progress Meetings:

2.6.5.1 The Contractor agrees to attend a post award conference convened by the contracting activity or contract administration office in accordance with

Federal Acquisition Regulation Subpart 42.5.

2.6.5.2 The Contracting Officer, COR, and other Government personnel, as appropriate, may meet periodically via teleconference or in person with the Contractor to review the Contractor's performance, at a location agreed upon by both EPA COR and Contractor. At these meetings the

Contracting Officer will apprise the Contractor of how the government views the Contractor's performance and the Contractor will apprise the

Government of problems, if any, being experienced. Appropriate action shall be taken to resolve outstanding issues.

2.6.5.3 The Contractor shall participate in quarterly conference calls scheduled by the EPA COR to discuss and coordinate activities across Region 5 Indian

Country.

2.6.6 Contracting Officer Representative (COR): An authorized Contracting Officer

(CO) will appoint a COR for this requirement by a separate letter. The letter of designation issued to the COR and a copy sent to the Contractor, states the responsibilities and limitations of the COR, especially with regard to changes in cost or price, estimates or changes in delivery dates. The COR is not authorized to change any of the terms and conditions of the resulting order. The CORs main responsibility is for monitoring all technical aspects of the contract and assisting the CO in contract administration. Examples of authorized COR functions assuring that the Contractor performs the technical requirements of the contract may include:

Perform inspections necessary in connection with contract performance;

Maintain written and oral communications with the Contractor concerning technical aspects of the contract;

Issue written interpretations of technical requirements, including

Government drawings, designs, specifications; and

Monitor Contractor's performance and notifies both the

Contracting Officer and Contractor of any deficiencies.

2.6.7 Key Personnel: The Contractor shall provide a Program Manager who shall be responsible for the performance of the work. The name of this person and an alternate who shall act for the Contractor when the Manager is absent shall be designated in writing to the contracting officer. The Contract Manager or alternate shall have full authority to act for the Contractor on all contract matters relating to daily operation of this contract. Qualifications for all key personnel shall include past experience with management, working with Tribal leadership, and trouble shooting of small Tribal Drinking Water Systems.

2.6.8 Contractor Travel: Contractor will be required to travel during the performance of this contract to attend meetings, to perform technical assistance and capacity development, or training. Non-routine travel such as an unscheduled request for technical assistance may occur if approved by the Agency. If an unscheduled, non-routine travel is approved by the Agency, travel expenses shall by consistent with the substantive provisions of the Federal Travel Regulation (FTR). Travel will be billed based on actual costs in accordance with GSA.

Part 3

Contractor Furnished Items, Services, and Responsibilities

3 CONTRACTOR FURNISHED ITEMS AND RESPONSIBILITIES:

3.1 General: The Contractor shall furnish all supplies, equipment, facilities and services required to perform the work.

3.2 Others Special responsibilities:

3.2.1 Identification of Contractor Employees: All contract personnel attending meetings, and working in other situations where their Contractor status is not obvious to third parties are required to identify themselves as a contractor to avoid a false impression that they are Government officials to their audience. The contract must ensure all documents or reports produced by contractors are suitably marked as contractor products or that contractor participation is appropriately disclosed.

3.2.2 For all site visits, the Contractor shall inform the PWS owner and utility representatives that they are contract employees (not EPA employees) contracted by EPA to provide EPA services. At all times, the Contractor shall be courteous to the PWS and tribal staff and any other personnel involved with the project.

3.2.3 If the Contractor observes that a PWS is not complying with any of the drinking water regulations or, if conditions at the facility pose an immediate public health risk, the Contractor shall immediately inform the EPA COR.

3.2.4 All work performed by the Contractor shall be done in accordance with pertinent

Occupational Safety and Health Administration requirements.

Part 4

Specific Tasks

4 SPECIFIC TASKS:

4.1 Task 1. Technical Assistance: The Contractor shall provide technical assistance to tribal public waters system utilities to assist in the correction of problems or deficiencies identified by monitoring and reporting results or sanitary surveys. The Contractor shall assist the tribes to correct deficiencies that are preventing the effective management and operation of their PWS. Examples of this type of work include, but are not limited to:

Work with water system personnel to bring the PWS into compliance, including disinfection of the system.

Work with operators troubleshooting contamination problems.

Provide assistance and maintenance support to operators to ensure the efficient operation of the PWS.

Work with the PWS to ensure accurate record keeping and reporting.

Assist and oversee if necessary, operators installing, troubleshooting, calibrating, and maintaining equipment, such as turbidity meters and chlorinators.

Provide assistance with specific system needs and identified problems.

Assist in training, modifying, and verifying tribal operators of regulated water systems with preparation of drinking water samples, in accordance with EPA approved calendars/schedules and site sampling plans.

Technical Assistance requests received directly from the tribes or IHS between the hours of 3:00 p.m. and 7:00 a.m. and weekends shall be immediately reported to the

EPA COR by phone.

4.2 Task 2. Capacity Development Initiative: The Contractor shall meet with the appropriate personnel for each Tribe to verify, maintain, and improve CD needs including past

Region 5 CD and training needs assessments. (Refer to Appendix I, CD Snapshot).

4.2.1 Subtask 2.1 – Current CD Assessment Initiatives: The Contractor shall assist the tribal PWS responsible personnel by reviewing and/or providing suggested improvement recommendations, if necessary, on the CD initiative components.

Quarterly, a teleconference meeting between the contractor and EPA shall occur to discuss the status of ongoing and proposed initiatives. Proposed initiatives may combine more than one CD component, if feasible. Assist Tribes in compiling awarded DWIG project packages. The following are the main CD initiative components:

Tribal Public Water System Utility Ordinances

Source Water Assessment and Protection Plan (SWAPP) o Climate Change Resilience Measures

Plans

Safety Plan addressing Operation and Maintenance activities

Emergency Response Plan/Vulnerability Plan (ERP/VA)

Budgets for financial management capacity

Cross Connection Control Program

Certified Operator Assistance and/or Educational Program

System-As-Built and/or related records

Energy Efficiency Assessments/Audits of PWS and related Utility

Systems

Water Loss Control Activities

Asset Management of PWS and related Utility Systems

4.2.2 Subtask 2.2 - Capacity Development Annual Tracking Sheet: The contractor shall annually coordinate and visit with all tribes to track CD. The contractor shall use the CD tracking sheet (See Appendix H) to reflect updates in the CD focal points over the year. The annual CD tracking sheet shall be completed and submitted by the end of each contract year, as described in the deliverables (Refer to Part 6).

The purpose of the CD deliverable is to assist EPA to determine priorities for the next year.

4.2.3 Subtask 2.3 - Public Water System Inventory Information Update: All Tribal water systems inventory shall be revised annually to reflect any changes. (Refer to Appendix C). The inventory shall include an on-site visit verifying the number and conditions of the wells, treatment units, flow, population served, and current site sampling plans for RTCR, and LCR (assist if needed to update plans with system submitting updated plan to EPA). EPA will furnish the most recent inventory at time of contract award. The site visit can be performed in conjunction with other tasks or subtask purposes. The inventory will also include scoring the systems with the appropriate state classification for public water systems and verifying certification level of the operators, as well as implementation status of source water protection programs. Detailed inventory information may be requested if the system is selected as part of the Drinking

Water Infrastructure Needs Survey and Assessment.

4.2.4 Subtask 2.4 ‑ Training Workshop(s): The Contractor shall provide for each state, two, 2-day workshops, open to all tribes, totaling 4 training events per year. One workshop shall be oriented toward Safe Drinking Water Act rules, new and current rules, reporting and compliance; the other workshops toward basic operator skills and knowledge needed to obtain/renew certification. Other relevant training topics in the workshops can include routine maintenance, troubleshooting, CD topics and additional topics recommended by the contractor and agreed upon by the EPA COR.

Part 5

Reference Materials

5 APPLICABLE PUBLICATIONS (CURRENT EDITIONS). The Contractor must abide by all applicable regulations, publications, manuals, and local policies and procedures. All guidance documents in this part are subject to change for update. EPA is responsible for delivering the most recent guidance documents and forms used in this work agreement.

5.1 Attachments/Technical Exhibits:

o Deliverables Schedule (Part 6) o Quality Assurance Surveillance Plan (Part 7) o Sanitary Survey Form (Appendix D) o Capacity Development Tracking Annual Sheet (Appendix H)

5.2 Guidance Documents

o Source Water Assessment and Protection Workbook Guidance o Cross Connection Control Program (Reference Appendix B) o Water System Inventory form (Reference Appendix C) o Water Loss Project example (Reference Appendix E) o Energy Checklist Outline (Reference Appendix F) o Active Tribal Public Water System List (Reference Appendix G) http://water.epa.gov/infrastructure/drinkingwater/sourcewater/protection/sourcewaterassessments.cfm

Part 6

Deliverables Schedule Deliverable Frequency Medium/Format* Submit To

System inventory updates

Annually Email Electronic copies

COR & Direct

Implementation Team.

Sanitary Survey As needed. When completed; it should be delivered no later than 30 days after completion.

Email Electronic copies

COR & Direct

Implementation Team.

Progress reports** No later than 15 days after the end of the month.

Email Electronic copies (negotiable format)

COR & Direct

Implementation Team.

Site Visit Reports

Objective, findings and accomplishments, recommendations and conclusions

Within 30 days of the on site visit or task.

Email Electronic copies.

COR & Direct

Implementation Team.

CD Tracking Sheet and narrative summarizing improvements and CD focused initiatives

Annually Email Electronic copies

COR & Direct

Implementation Team.

Weekly Schedule Each personnel under the contract shall send a weekly schedule outlining weekly travel and activities.

Email Electronic copies

COR & Direct

Implementation Team.

Training needs / planning / agendas

30 days before workshop Official Agenda

Email Electronic copies

COR & Direct

Implementation Team.

PWS RTCR assessments COR and contractor request/cannot be defined ahead. Will work with RTCR compliance officer as well as COR.

PWS GWUDI

assessments

COR and contractor request /cannot be defined ahead

*All formats must be Microsoft Read Format

**Monthly Progress Reports: The monthly reports will report on the work projects and activities conducted for each tribe. The monthly report shall include a current and cumulative financial summary for work that has been performed. The monthly report shall also include a brief description of projects and activities to be conducted in the following month. It may or may not include site visit reports.

**Deviation(s) may be allowed only by the consent of contract officer and /or the COR

Part 7

Quality Assurance Surveillance Plan

INTRODUCTION: This Quality Assurance Surveillance Plan (QASP) sets forth the procedures and guidance that EPA will use in evaluating the technical performance of the contractor. The QASP defines how the Government will monitor the contractor’s performance.

The QASP provides a systematic method to evaluate the services the contractor is required to perform. The contractor, and not the Government, is responsible for management and quality control actions to meet the terms of the contract. The role of the government is to ensure quality assurance standards are achieved.

The contractor service requirements are summarized into performance objectives that relate directly to mission essential items. The performance threshold briefly describes the minimum acceptable levels of service required for each requirement. These thresholds are critical to mission success. Standards and thresholds may be revised every ‘option’ year in order to further specify or accommodate the Regional Safe Drinking Water Program needs and goals;

however, the needs and goals will not be out of the scope previously detailed in the Part 4 of this document.

PURPOSE OF THE QASP: The QASP provides the EPA Contracting Officer Representative

(COR) and EPA Contracting Officer (CO) the ability to conduct surveillance activities of contractor performance during the life of the contract. The QASP details how and when EPA will monitor, evaluate, and document contractor performance in the areas outlined in the

Performance Work Statement. The contractor develops and submits the Quality Plan (QP) for

Government acceptance in order to comply with contract deliverables. Once accepted, the contractor then uses the QP to guide and document the implementation of the required management and quality control actions to achieve the specified results.

QASP is intended to accomplish the following:

(1) Roles and responsibilities of participating Government officials:

Contracting Officer (CO) – The government employee responsible for executing, administering, and providing direction on the Contract. This person is duly appointed with the authority to enter into, administer, or terminate contracts and make related determinations and findings on behalf of the Government.

Contracting Officer Representative (COR) – The government employee who is responsible for oversight of the Contract. The Contracting Officer designates as a

Contracting Officer Representative in writing specific technical and administrative roles and responsibilities to assist in administering the contract. The source of the

COR authority is the Contracting Officer. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the

Government’s behalf. Any changes that the Contractor deems may affect contract, price, terms, or conditions shall be referred to the Contracting Officer for action.

(2) Key deliverables that will be assessed, Rating Elements, and

Standards of Performance against which the Contractor’s performance will be assessed for Key Deliverables. Though the Government, through its CO/COR will monitor the Contractor’s performance on a continuing basis, the volume of tasks performed by the Contractor makes technical inspections of every task and step impractical. The performance measures summary is located in the matrix below. The summary includes the required service(s), performance standard(s), acceptable quality level(s), and method of surveillance for each work element and is outlined below:

a. Process of quality assurance assessment. A determination of the contractor’s overall performance will be on an annual basis. EPA will provide annual customer feedback to the contractor by summarizing the past year’s surveillance activities using the Contractor Performance Assessment Reporting System

(CPARS) and Past Performance Information Retrieval System (PPIRS) metric tools to measure the quality and timely reporting of past performance information. As soon as noteworthy accomplishments or discrepancies are identified with a deliverable generated by the contract, the COR and CO will notify the contractor.

b. Monitoring quality assurance. The COR will provide documentation to the

Contracting Officer and maintain a complete Quality Assurance file. The file will contain copies of all reports, evaluations, recommendations, and actions related to the Government’s performance of the quality assurance function. All such records will be retained for the life of this contract. The COR shall forward these records to the Contracting Officer at termination or completion of the contract.

Performance Objective Standard Performance

Threshold

Method of Surveillance

The Contractor shall provide technical assistance and respond to requests from utilities and as directed by EPA

COR to assist in correction of problems or deficiencies identified by monitoring and reporting results or sanitary surveys. Assist in correction of deficiencies needed to effectively manage and operate their systems.

(See part 4.1)

1. Assistance will be provided to operator for contamination problems and compliance issues within 24 hours of being notified by

EPA COR

Zero deviation from standard.

EPA contact Tribe &

IHS

2. The Contractor conduct sanitary surveys (as needed/ requested from

EPA)

Zero deviation from standard.

Sanitary survey reports delivered to EPA.

EPA contact Tribe &

IHS

3. Addressing system significant deficiencies, system noncompliance, corrective actions identified in monthly reports or sanitary surveys

Zero deviation from standard.

EPA contact Tribe &

IHS

4. 95% of acute contaminants

(RTCR & Nitrate) related with compliance problems will be addressed within 3 days.

Zero deviation from standard

EPA contact Tribe &

IHS

EPA will monitor compliance with

Drinking Water

Requirements to ensure that 95% of acute contamination problems are addressed within 3 days after being identified to the

Contractor.

Contractor shall carry on

Capacity Development

(CD) initiatives with each Tribe as—capacity development tasks and initiatives include all components referenced in section 4.2.

1. Annually update

Public Water

System Inventory

Zero deviation EPA contact Tribe &

IHS

EPA Follow up and update on Public Water

System Inventory.

2. Conduct site visits for Drinking water systems in order to assess and update their CD activities

Zero deviation EPA contact Tribe &

IHS

EPA DI staff to follow up on reports and check on site visits and contact systems for check- ups.

3. Improve awareness on various CD components

Zero deviation EPA contact Tribe &

IHS

Provide list of workshop attendees as well as measure (via survey) improved capacity development awareness after the workshop/training. –

EPA DI staff to follow up directly with PWS operators.

4. Assisting Tribes with DWIG-TSA criteria for infrastructure project funds when the tribe is selected for award review.

Zero deviation EPA contact Tribe &

IHS

Help the tribe to complete and submit CD requirements for DWIG

TSA granted projects.

5. Focus on one or more CD components from the list described in part 4. Each year, EPA will identify the priority CD initiatives

Zero deviation EPA contact Tribe &

IHS

6. Completion of

CD annual forms

Zero deviation EPA contact Tribe &

IHS

Submit complete forms at end of option year.

APPENDIX A

Qualifications

Special Qualifications: Contractor shall have previous technical, managerial, and financial experience and knowledge working with small water systems and Tribal Governments. Contractor(s) should be a licensed operator and have a minimum of a Class C and/or B Water operator certification.

Program Manager

Education: Bachelor's Degree in any of the following fields: Geology, Engineering, Hydrology, Chemistry, Biology or other related field with a background to be able to identify and evaluate public water supply safety and provide public health protection to drinking water customers located on the Region 5 Indian Community.

General Experience: Two years in environmental policy management, water, wastewater or solid waste.

Knowledge of Safe Drinking Water Act.

Skills: Demonstrated minimum project management skills, including but not limited to planning, troubleshooting and accomplishment of milestones. Required efficient communication and reporting capabilities.

Tribal Technical Assistant Provider

Education: Bachelor's Degree or Life Experience in any of the following fields: Geology, Engineering, Hydrology, Chemistry, Biology or other related field with a background to be able to identify and evaluate public water supply safety and provide public health protection to drinking water customers located on the Region 5

Indian Community.

General Experience: Minimum of 5 years of related experience in Water, wastewater or related fields.

Experience with Computers.

APPENDIX B

Project Title - Cross Connection Control Programs

Project Description In order for EPA to reach its national goal of seeing that communities have access to “safe” drinking water, all water Utilities must have Cross Connection Control programs. The bottom line on this type of program is knowing where the testable backflow prevention devices are located on the system and making sure each device is tested on an annual basis.

A concerted effort has been made in Region 5 over the last couple of years to help the Tribes develop and implement this part of their program. Being this is still a voluntary program within Indian Country, Region 5 has taken many steps to help the Tribe’s gear up to take this project on.

In 2009 inspections were completed at all of the commercial facilities on the community water systems. Another step, and probably the most difficult, involved working with each tribal utility to address the deficiencies found.

The tribal circuit rider has and is performing this work. There were no outside funds to help the tribes correct the deficiencies found during the surveys. Each tribe was, and is, being expected to budget for the repairs. The managers are working with the various department heads to educate and acquire commitments. Some deficiencies may take a year or two to get corrected.

The last step in this project also involved the provision of additional resources. The tribal utilities may need to receive:

- Additional training on how to interrupt backflow device testing reports.

- Sample cross connection control ordinances so that they could amend their utility ordinances.

- Cross connection control videos/DVD’s for staff training and public education.

- EPA’s cross connection control manual.

- State-specific cross connection control guidance

- Names and phone numbers of all licensed plumbers certified to test and repair backflow prevention devices, by county.

- Educational literature for distribution to their customers.

- Assistance in prioritizing deficiencies for repair/replacement.

- Hose bib type vacuum breakers for residential hose bibs.

- Assistance in setting up a master file for all testable backflow devices found on their systems.

- And, on-going assistance from the Circuit Rider.

Benefits

- Improved Public Health Protection

- Improved Utility Programs

- Improved awareness of cross connection control by the Utility and the public

- Backflow devices are now being tested annually

- Hazardous conditions have been identified and corrected

- Improved awareness of the importance of the Utility Program and staff

- Testable backflow devices have been located and inventoried

- The water systems are safer

Project Duration The project is a multi-year effort. Getting deficiencies corrected after the surveys are performed is an on-going challenge unless an outside funding source is available to help cover the cost of repairs.

Project Contact, R5, Groundwater & Drinking Water Branch

Primary- Mostafa Noureldin, Phone (312)-353-4735, Noureldin.mostafa@epa.gov

Alicia Brown. Phone (312)-886-4443, Brown.alicia@epa.gov mailto:Noureldin.mostafa@epa.gov mailto:Brown.alicia@epa.gov

APPENDIX C

Water System Inventory Form

Basic Information / Annual Operating Period

Water System No. (PWS ID#) System Name

Date System Became Active: (MM/DD/YYYY)

Operating Category (Operator License)

Total Design Capacity In Gallons Per Day Total Emergency Capacity In Gallons Per Day

Start Date MM/DD (Date system begins operating each year)

End Date MM/DD (Date system ends operating each year)

Population Served

Average Daily

Resident Population (Year-round)

Average Daily

Transient Population

Average Daily

Non-Transient

Population

Effective Dates (MM/DD) From:

To:

Effective Dates

(MM/DD)

From:

To:

Effective Dates

(MM/DD)

From:

To:

Service Connections

Total Number of Service

Connections

Number of

Service

Connections by

Type

Residential _______

Commercial _______

Meter Type :

ME - Metered, UM - Unmetered, MU - Metered and Unmetered

Service Area Characteristics

This water system exists to provide drinking water to:

(circle all that apply)

School - (SC)

Mobile Home Park - (MH)

Service Station - (SS)

Day-Care Center - (DC)

Campground - (CA)

Hotel/Motel - (HM)

Other Transient Area - (OT)

Restaurant - (RE)

Medical Facility - (MF)

Residential Area - (RA)

Other Residential Area - (OR)

Tribal Building - (TB)

Recreation Area - (PA)

Casino Resort - (CR)

Other Non-transient Area (ON)

Points of Contact

Contact Type Tribal Chairperson / President Business Phone

Name Emergency

Phone

Address Line 1 Fax Number

Address Line 2 Email Address

City State Zip

Points of Contact

Contact Type Operator Business Phone

City State Zip

Points of Contact (Optional)

Contact Type Choose all that apply from the list below:

Business Phone

City State Zip

Points of Contact (Optional)

Contact Type Choose all that apply from the list below:

Business Phone

City State Zip

IE = Indian Health Service

Engineer

IS = Indian Health Service

Sanitarian

OP = Operator

OW = Owner

PC = Primary Contact

RC = Regulatory

Contact

LC = Legal Contact

TC = Tribal Chairperson / President

TE = Tribal Environmental Dept.

Representative

TG = Tribal Government

Representative

TH = Tribal Health Dept.

Representative

UT = Utility Representative (Tribal)

O= Other

Water System Facilities - Wells

Facility Name

(Well name)

EPA Assigned No.

(Well ID) (i.e.WL01)

Constructed

Date

Active? Yes

No

Activation

Date

/ / Inactivation Reason

Availability P - Permanent E - Emergency S - Seasonal I - Interim

(Well name)

EPA Assigned No.

(Well ID)

No

Activation

Date

(Well name)

EPA Assigned No.

(Well ID)

No

Activation

Date

Treatment Plants

Facility Name (Plant name) EPA Assigned No. (ID #) FINDS No.

Active? Yes

No

Activity Date / / Activity

Reason

Constructed / /

Enter Actual Plant Location Below Availability P - Permanent E - Emergency S - Seasonal I - Interim

Street Address City /

Town

State Zip Code

Treatment Objective Associated Treatment Process

Treatment Objective Associated Treatment Process

Treatment Plants

Facility Name (Plant name)

EPA Assigned No.

(ID #)

FINDS No.

Active ? Y N Activity

Date

/ / Activity

Reason

Constructe d

Enter Actual Plant Location Below Availability P - Permanent E - Emergency S - Seasonal I - Interim

Street Address City /

Town

State Zip

Code

Treatment Objective Types

B = Disinfection By-products Control

C = Corrosion Control

D = Disinfection

E = Dechlorination

F = Iron Removal

I = Inorganics Removal

M = Manganese Removal

O = Organics Removal

P = Particulate Removal

R = Radionuclides Removal

S = Softening (Hardness Removal)

T = Taste/Odor Control

Z = Other

CODE PROCESS

B121 Activated Carbon, Granular

B125 Activated Carbon, Powdered

B141 Aeration, Cascade

B143 Aeration, Diffused

B145 Aeration, Packed Tower

B147 Aeration, Slat Tray

B149 Aeration, Spray

B160 Algae Control

B200 Chloramines

B220 Chlorine Dioxide

B240 Coagulation

B344 Filtration, Pressure Sand

B345 Filtration, Rapid Sand

B360 Flocculation

B500 Lime - Soda Ash Addition

B541 Ozonation, Post

B543 Ozonation, Pre

B600 Raapid Mix

B640 Reverse Osmosis

B660 Sedimentation

B720 Ultraviolet Radiation

B741 pH Adjustment, Post

B742 pH Adjustment, Pre

C441 Inhibitor, Bimetallic Phosphate

C443 Inhibitor, Hexametaphosphate

C445 Inhibitor, Orthophosphate

C447 Inhibitor, Polyphosphate

C449 Inhibitor, Silicate

C680 Sequestration

C740 pH Adjustment

C741 pH Adjustment, Post

D200 Chloramines

D220 Chlorine Dioxide

D346 Filtration, Slow Sand

D401 Gaseous Chlorination, Post

D403 Gaseous Chlorination, Pre

D421 Hypochlorination, Post

D423 Hypochlorination, Pre

D541 Ozzonation, Post

D543 Ozonation, Pre

D720 Ultraviolet Radiation

E121 Activated Carbon, Granular

E141 Aeration, Cascade

E143 Aeration, Diffused

E145 Aeration, Packed Tower

E147 Aeration, Slat Tray

E149 Aeration, Spray

E620 Reducing Agents

E623 Reducing Agent, Sodium Bisulfate

E625 Reducing Agent, Sodium Sulfite

E627 Reducing Agent, Sulfur Dioxide

F141 Aeration, Cascade

F143 Aeration, Diffused

F145 Aeration, Packed Tower

F147 Aeration, Slat Tray

F149 Aeration, Spray

F300 Distillation

F343 Filtration, Greensand

F344 Filtration, Pressure Sand

F345 Filtration, Rapid Sand

F403 Gaseous Chlorination, Pre

F423 Hypochlorination, Pre

F543 Ozonation, Pre

F560 Permanganate

F580 Peroxide

F640 Reverse Osmosis

F660 Sedimentation

F680 Sequestration

F700 Sludge Treatment

F740 pH Adjustment

F742 pH Adjustment, Pre

I100 Activated Alumina

I121 Activated Carbon, Granular

I180 Bone Char

I240 Coagulation

I300 Distillation

I320 Electrodialysis

I344 Filtration, Pressure Sand

I345 Filtration, Rapid Sand

I360 Flocculation

I460 Ion Exchange

I500 Lime - Soda Ash Addition

I600 Rapid Mix

I640 Reverse Osmosis

I660 Sedimentation

I680 Sequestration

I700 Sludge Treatment

I742 pH Adjustment, Pre

M300 Distillation

M343 Filtration, Greensand

M403 Gaseous Chlorination, Pre

M423 Hypochlorination, Pre

M543 Ozonation, Pre

M640 Reverse Osmosis

M680 Sequestration

N000 No Treatment / Not Applicable

N997 Treatment Applied at Plant

The first letter of each code is the objective of the treatment:

B = Disinfection By-products Control

C = Corrosion Control

D = Disinfection

E = Dechlorination

F = Iron Removal

I = Inorganics Removal

M = Manganese Removal

O = Organics Removal

P = Particulate Removal

R = Radionuclides Removal

S = Softening (hardness removal)

T = Taste/Ordor Control

Z = Other

N998 Treatment Applied at Point of Entry

O121 Activated Carbon, Granular

O125 Activated Carbon, Powdered

O141 Aeration, Cascade

O143 Aeration, Diffused

O145 Aeration, Packed Tower

O147 Aeration, Slat Tray

O149 Aeration, Spray

O160 Algae Control

O240 Coagulation

O300 Distillation

O345 Filtration, Rapid Sand

O360 Flocculation

O403 Gaseous Chlorination, Pre

O423 Hypochlorination, Pre

O543 Ozonation, Pre

O560 Permanganate

O580 Peroxide

O620 Reducing Agents

O640 Reverse Osmosis

O660 Sedimentation

O742 pH Adjustment, Pre

P240 Coagulation

P300 Distillation

P341 Filtration, Cartridge

P342 Filtration, Diatomaceous Earth

P344 Filtration, Pressure Sand

P345 Filtration, Rapid Sand

P346 Filtration, Slow Sand

P347 Filtration, Ultrafiltration

P360 Flocculation

P520 Microscreening

P600 Rapid Mix

P660 Sedimentation

P700 Sludge Treatment

P742 pH Adjustment, Pre

R100 Activated Alumina

R121 Activated Carbon, Granular

R141 Aeration, Cascade

R143 Aeration, Diffused

R145 Aeration, Packed Tower

R147 Aeration, Slat Tray

R149 Aeration, Spray

R180 Bone Char

R240 Coagulation

R300 Distillation

R320 Electrodialysis

R344 Filtration, Pressure Sand

R345 Filtration, Rapid Sand

R360 Flocculation

R460 Ion Exchange

R500 Lime - Soda Ash Addition

R600 Rapid Mix

R640 Reverse Osmosis

R660 Sedimentation

R680 Sequestration

R700 Sludge Treatment

R742 pH Adjustment, Pre

S240 Coagulation

S300 Distillation

S344 Filtration, Pressure Sand

S345 Filtration, Rapid Sand

S360 Flocculation

S460 Ion Exchange

S500 Lime - Soda Ash Addition

S600 Rapid Mix

S640 Reverse Osmosis

S660 Sedimentation

S680 Sequestration

S700 Sludge Treatment

S742 pH Adjustment, Pre

T121 Activated Carbon, Granular

T125 Activated Carbon, Powdered

T141 Aeration, Cascade

T143 Aeration, Diffused

T145 Aeration, Packed Tower

T147 AEration, Slat Tray

T149 Aeration, Spray

T160 Algae Control

T403 Gaseous Chlorination, Pre

T423 Hypochlorination, Pre

T543 Ozonation, Pre

T560 Permanganate

T580 Peroxide

P348 Filtered

P349 Unfiltered - Successfully Avoiding

N350 Unfiltered, but Required to Filter

Entry Point / Sampling Location

(Entry Point Name)

EPA Assigned

No. (Well ID)

Constructed Date

Active? Yes

No

Activation

Date

Entry Point / Sampling Location

(Entry Point Name)

EPA Assigned

No. (Well ID)

Constructed Date

Active? Yes

No

Activation

Date

Storage Facilities

(Well name)

EPA Assigned

No. (Well ID)

Constructed Date

Active? Yes

No

Activation

Date

/ / Inactivation Reason

Availability P - Permanent E - Emergency S - Seasonal I - Interim

Storage Type BL - Bladder EL - Elevated GR - Ground RS - Reservoir UN - Underground HD - Hydropneumatic ST

- Standpipe

Constructed Material

(Circle One)

Asbestos Cement, Asphalt, Concrete, Copper, Earth, Fiberglass, Plastic, Steel, Wood, Other

Coating Type

(Circle One)

Approved Paint, Epoxy Resin, Fiberglass, Greased, Glass Lined

Steel, Non-Approved Paint, Plastic, Unlined, Other

Storage Capacity in Gallons Total Elevation Head

Signature_______________________________________

Date___________________________________________

Please follow the example diagram given below and draw a diagram of your water system on the next sheet showing the wells, treatment plants, entry points and distribution system and how they are all connected.

Anytown River

Treatment

Plant #2

Treatment

Plant #1

Well

#5

Well

#1

Well

#2

Well

#3

Well

#4

Well

#6

Anytown USA distribution system

EP #1

EP #6

EP #2

EP #3

EP #5

EP #4

C hlor inator

Anytown, USA

Valv e

E mergency

Hook-up to

RWS

Intake

Adams

C ounty

J ac k s on

C ounty

123 Riverfront Road234 Riverfront

Road

APPENDIX D

Sanitary Survey Form Template

1. Basic System Information

* PWS Number Water System Name: Date:

Tribal Name

Address, Street- City -

State / County - City -Zip code

Service Area Type Code:

Seasonal --> Type

Begin Date

System Classification : End Date

* Recommended Certification Level (is it met?)

Stake holders

Legal Entity Name Address Phone Number Legal Entity Code Comments

Owner

Administrative Contact

Chief Operator

Other

Sanitary Survey Inspectors

Operators in Charge

Name

Staffing and Certification Information Present since: (approximate date)

Position Certification/Agency

2. System General Description

Population Water Capacity

Populations Served Average Daily Demand (MGD)

Residential Peak Daily Demand (MGD)

Transient Total Production Capacity (MGD)

Non-Transient Source Water type

Number Connections ( Approx.)

* Does the system sell or purchase water from / to another system? (Is that notified in R5 EPA system)

List of Major Facilities and Description

Name Description Date: Since (mm/ yyyy)

Planned Future Capital Improvement Projects

Name Description Date: Since (mm/ yyyy)

3. Well Information (One sheet / Well)

Well log

Well Name: Well ID: Depths, (feet)

Well Pump Intake Water Grout Casing

Date Constructed Pump

Activity Code: Type

Availability Code Power (HP)

Casing Type Alternative power

Casing Diameter (in.) Pumping record

Well Conditions Y/N Comments

1. Is site security Adequate?

2. Is well house or pump subject to flooding?

3. Does all equipment have adequate access for repair/replacement?

4. Is the overall pump condition good?

5. Is lightning protection available for the pump?

6. Is electrical equipment secured against weather, insects and animals?

7. Type alarm present for pump failure?

8. Is the pump equipped with the following: Check valve - Isolation valve

- Air relief valve - Flow meter - Disinfection Meter Pressure gauge? State if there is a shortage of any.

9. Does the well have a blow off?

* 10. Does the well have a raw water sample tap?

* 11. Does the well have a treated water sample tap?

* 12. Does the casing extend at least 12" above ground level?

* 13. Is the well vent intact and at height of at least 18" above ground level?

* 14. Is the sanitary seal intact?

* 15. Is there a pad (usually concrete) around the well?

16. Is the well under the influence of surface water? Does the well need a

GUDI test/evaluation?

17. Is the well near any sources of contamination?

18. Redundancy operation? (e.g. back up pump - well source)

19. Is there an emergency well source? What is its condition?

4. Disinfection; If other disinfection technique than chlorination is used, please state and highlight here:

* What is the disinfectant residual concentration target in the distribution system? Or at the first customer?

Is mixing adequate?

Maintain backup chlorine stock?

Liquid Chlorination:

What type of Disinfection is used? Is liquid solution adequately mixed? Is liquid solution tank covered? Are there spill containment provisions?

Can the feed pump operate within the necessary range?

How often is dosage checked? What is the chlorine usage rate? Is the disinfection building safe and secure?

What is the chlorine residual goal? Where is the disinfection application point?

Is mixing adequate?

Continuous Operation? Adequate stand-by valve?

Is there a fail safe device attached to a flow switch?

Are daily operating records maintained? Have there been any interruptions in disinfection?

Is residual measured daily at the feed point?

Gas Chlorination:

Is a method for leak detection present? Is the chlorination equipment properly contained?

Is the chlorination room vented properly? Does the chlorination room door open out with a panic bar?

Are cross connections present in the chlorination room?

If more than one gas cylinder, is there an automatic switchover between tanks?

Are the cylinders on a working scale? Is a wrench in place on open gas cylinders?

Are gas cylinders properly marked and restrained?

What is the operating condition of the chlorinator?

Vented to the Outside? Control Switch Outside?

Are the Cylinders properly restrained? ( usually chained) Existing safety equipment?

5. Other Chemicals & Feed Facilities

Chemical Characteristics Pumps Compliance

Name /

Function Dosage

Point of Use

(location)

Chemical storage quality

Method for

Determining

Dose

Number Types Condition;

Capacity

Calibration frequency

* Lack of treatment, specify what kind of treatment and why is it needed?

Fluoridation

Name of Fluoridator:

Which fluoride testing method is used?

How often is pump being calibrated?

Is the flow metered? (Meters should be on the inlet side of the saturator)

Fluoride residual goal (mg/L)

Is saturator wired for fail - safe device?

6. Distribution System and Pumping

Distribution System

* System Pressure Range (units psi) / Water pressure drops incident frequency.

Are distribution system maps complete?

Number of pressure zones Is the system interconnected with any other systems?

Number of hydrants (flush and fire) * Does the system have adequate valving? Are relief valves screened?

Number of Dead End Lines - High DBPs concentration? Are leaks/breaks frequent or numerous? Pipes/main condition?

How many PRV are present? Any issues? Does the system have construction standards? Any defective or missing manhole covers?

Pumping to Distribution system

Name of Pump Station:

Describe pumps present (Number of pumps including reserve, types, function, capacity (gpm), horsepower):

Are flow meters present? Are flow records kept?

Are redundant pumps present? Is there an isolation valve for each pump?

Pumping to Distribution System Continued

Do Pumps have excessive vibration or heat when running?

Is lubrication oil food grade and in good shape?

Are Pump Capacities Adequate (For production pumps: Able to meet average daily demand with largest pump down for 18 hours)?Are flow meters present? Are flow records kept?

Are cross connections present at water lubricated pumps? Is each pump equipped with a check valve?

Are adequate alarms present? Fail safe?

In the case of Booster pumps, is there a pressure gauge on the suction and discharge side of the pump?

* Is there a fail safe to prevent the suction pressure from going below 10 psi?

* Is the discharge side pressure excessive?

Pumping Facilities (pump house)

Is the pump facility used for incompatible storage? Is the facility secure?

Is the facility subject to flooding? Are pump controls in good shape and protected from the elements?

7. Storage, (Elevated Tank (ET) - Underground (UG) , Hydro Pneumatic (HP), Other...)

Name of Storage Tank:

Type of Material / tank type Capacity - date of construction Time since last Cleaning? What is the clean up process duration

(approx. days or hours) ?

Is the storage capacity adequate? What is the on-site storage in case of clean ups?

Time of last Inspection? Avg Detention time (days)?

One or two pipes? (Mixing conditions)

Is the tank continuously operated? How? Air water ratio if HP)

Can tank be isolated from the system?

* Is the hatch locked and constructed properly? Other unsealed opening?

Is site security adequate? Internal Condition / Type of

Internal Coating.

Safety: (cable or a cage for

ET, labeled confined space for UG)

External Condition - (e.g.

exterior pipe, wall corroded)

* Drain /overflow and valves conditions; Do overflows have splash pads?

* Vent and vent screen condition Overflow Condition

Do overflows terminate between 12" and 24" above the splash pad?

For the ET; do the tower have one or two pipes? for supplying water / discharging water to/ from the tower?

* Old storage tanks connected to the system? Abandoned properly?

Does the level indicator work properly?

* Note: Check and / or Request any copies of pictures taken from the last inspection.

8. Management

Financial Information

Does the system have an annual operating Budget? Does the system bill for water? What is the water rate and when it was last updated?

Does the system develop an annual financial report? Does the system have emergency funding?

Does the system apply meters to all system connections? Are there sufficient funds for staff training?

How are spending decisions made?

Planning

Is management aware of present problems at the system? Has someone at the system prioritized repair/replacement of critical assets?

What Disinfection procedure is used for new lines and repairs?

Does the system have a flushing program? Hydrant / valves exercise program?

Does the system have a coliform monitoring plan?

Does the water system have a preventive maintenance program?

Does the system have a master plan? As built maps updated? Is there effective communications between management, operators and customers?

Has a Capacity Assessment been completed? Is management familiar with SDWA requirements?

Are records kept according to requirements? Is monitoring/testing adequate?

*MORs - 3 years

*Bacti analyses - 5 years Does the system do CCR reports? Does the system send required public notifications?

*Chemical analyses - 10 years

*Documentation of Corrective Actions - 3 years Safety plan for utility workers?

*Sanitary Survey Reports - 10 years

Does the system have a list of critical customers? Examples. Does the water system have an adequate spare parts inventory?

Operations

Does the system have a maintenance plan? ( work orders system)

* Does the system have sampling taps after treatment( for compliance purposes)?

* Facility / Plant control system; (SCADA - Alarms - monitoring) adequacy?

* Wiring conduits exist at electrical/mechanical equipment?