Fillable Printable Form 5299
Fillable Printable Form 5299
Form 5299
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LEVEL 1 ASSESSMENT –
NON-TRANSIENT NON-COMMUNITY (NTNC) OR
COMMUNITY PUBLIC WATER SYSTEM (PWS)
State Form 52998 (R / 9-16)
Indiana Department of Environmental Management
Office of Water Quality – Drinking Water Branch
PWSID Number: SYSTEM NAME:
Section A - Review and evaluate: Check for any potential causes of contamination identified or check
“N/A” if the section is not applicable to your system. Each section requires a response.
1. SAMPLING SITES Issue identified: YES NO
unclean or unsuitable tap
change or damage to sampling location
low disinfection residual (if applicable)
unapproved sampling location
other:
2. SAMPLING PROTOCOL Issue identified: YES NO
tap wasn’t flushed (prior to sampling)
tap wasn’t disinfected (prior to sampling)
aerator or screen damaged or corroded
improper hold time / storage temperature
old sample bottle / bottle seal broken
new person collected water sample
sample error (e.g. touched inside of cap/bottle)
other:
3. OPERATIONAL CHANGES Issue identified: YES NO
water quality parameters out of range
new sample tap installed
new treatment device added
source added / abandoned
visible indicators of unsanitary conditions
recent repairs to distribution system
loss of power
other:
4. DISTRIBUTION SYSTEM Issue identified: YES NO
low flow / dead end main
low disinfection residual (if applicable)
main breaks
low pressure (less than 20 psi)
water leaks
installation of new mains/construction
cross connection* issue(s)
illegal use of hydrants
flushing of fire hydrants or blow-offs
loss of water pressure
booster pump failure
other:
5. TREATMENT (if applicable) Issue identified: YES NO N/A
treatment device malfunctioning
treatment added or changed
cross connection* issue(s)
inadequate disinfection
interruption in treatment / power loss
chemical feed rate problems
filter or media contamination
chemical day tanks empty / inadequately sealed
maintenance schedules not followed
evidence of contamination
turbidity measurements out of range
other:
* A cross connection is any actual or potential connection between a potable water supply and a non-potable
source (e.g. water softener waste line plumbed directly to floor drain with no air gap).
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6. STORAGE / BLADDER TANK(S) Issue identified: YES NO
tank(s) is damaged, rusty, or has holes
tank bladder(s) is water logged
hydropneumatic tank malfunctioning
vent / overflow screen missing or damaged
signs of vandalism / unauthorized access
recent work or repair of tank
evidence of contamination
standing water / debris around tank
access hatch not sealed
water age / inadequate turnover
lack of maintenance, cleaning, or inspection
other:
7a. SOURCE – WELL(S) (if applicable) Issue identified: YES NO N/A
cracked, broken, or missing well cap
cracked or damaged well casing
well vent screen missing or damaged
missing or damaged grout seal
recent work on pump
well pump cycling properly
unprotected opening in pump assembly
evidence of contamination
flooding or standing water near well
standing water / flooding in well pit
ground slopes toward well casing
air relief valve missing screen and / or air gap
well head is buried or has space around casing
other:
7b. SOURCE – SURFACE WATER (if applicable) Issue identified: YES NO N/A
increased raw water turbidity readings
temperature changes
rain events
intake structure damage
raw water indicates potential for contamination
other:
Section B - Issue Description: Use this space to provide additional information on potential causes of
contamination identified during the assessment. If possible, include corresponding dates with your
findings. Attach additional pages as necessary.
Check if you did not find any causes for the contamination.
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Section C - Corrective Action Taken or to be Taken: Use this space to describe corrective actions
completed, a proposed timetable for any corrective actions not already completed, and any interim
measures that you plan to implement. Attach additional pages as necessary.
Check if you did not find any causes for the contamination.
Certification: I certify, under penalty of law, that this document was prepared by me, and the
information submitted is to the best of my knowledge and belief, true, accurate and complete.
I am also aware that there are significant penalties for submitting false information.
Print Name: License Number (if applicable):_______________
Signature: __________________________________ Date
(month, day, year): ____________________
Email: __________________________________ Telephone: __________________________
Please save a copy and return this form to the Indiana Department of Environmental Management.
IDEM Use Only: IDEM Reviewer: ________________________
Level 1 Assessment Accepted:
YES NO
PWS has corrected the problem:
YES NO
Corrective Action Plan approved:
YES NO
Approved with changes:
YES NO
Comments: __________________________________________
____________________________________________________
____________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Mail, email, or fax this form and any
supporting documents to the
Drinking Water Branch of:
Indiana Department of Environmental
Management
100 N Senate Ave IGCN 1201
Indianapolis, IN 46204
E-mail: [email protected]
Fax: 317
-
234
-
7462
