3930-FM-BSDW0501B
Rev. 2/2015
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF SAFE DRINKING WATER
Sanitary Survey Checklist Module 1B
SURFACE SOURCES
PWS NAME
PWS ID #
SURVEY DATE
SOURCE(S) ID # / NAME
YES NO UNK N/A
SURFACE WATER INTAKE PROTECTION AREA INFORMATION
1B-1. Is the Zone A source water intake protection area owned by the PWS or controlled by a long-term lease or
deed restrictions?
1B-2. Use the table below to indicate the presence of any potential sources of contamination (PSOCs) present in
the Zone A and Zone B surface water intake protection areas and what risk reduction measures are being
used. If no PSOCs are present for existing land uses, use the RRM line to describe the condition of the land
use.
Zone A Zone B
PSOCs PSOCs RRM
Existing Land Uses & Associated Risk Reduction Measures (RRM)
Agriculture
describe RRMs:
Residential
describe RRMs:
Industrial
describe RRMs:
Forest
describe RRMs:
Waterways
describe RRMs:
Transportation
describe RRMs:
Storage tanks
describe RRMs:
Solid waste
describe RRMs:
Land Development
describe RRMs:
Oil & gas facilities
describe RRMs:
Mining
describe RRMs:
Abandoned Mine Drainage
describe RRMs:
1B-3. Has Zone B land use changed since the last waiver approval or Sanitary Survey?
If Yes, list how:
1B-4. Does the PWS interact with agencies and governmental bodies with jurisdiction or mutual interests within the
watershed?
If Yes, list them:
SOURCE WATER QUALITY AND QUANTITY INFORMATION
1B-5. Is a raw water sample tap available for routine monitoring?
1B-6. Are raw water quality measurements taken?
If yes, what is measured and how often?
What treatments have been modified as a result of the measurements?
1B-7. If the PWS experiences seasonal algae blooms, is copper sulfate or other approved measure utilized for
algae control?
1B-8. Does the PWS utilize wildlife controls? If Yes, describe:
1B-9 If intake levels can be adjusted, are they adjusted to obtain the best water quality?
1B-10. Is the source adequately metered and does the PWS maintain records of water production?
Module 1B
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Surface Sources
3930-FM-BSDW0501B
Rev. 2/2015
Water Allocations Permitted Sources:
1B-11. Does the PWS submit monthly reports of daily withdrawal and instream flow requirements?
1B-12. Are passby flow measuring devices installed and maintained?
INTAKE CONSTRUCTION INFORMATION
1B-13. Are all pumps and controls operational and maintained?
1B-14. Is emergency backup power available and tested?
1B-15. Are all valves and meters operational and maintained?
1B-16. Is the pumphouse in good condition and maintained inside and outside?
1B-17. Is the pumphouse protected from unauthorized personnel?
1B-18. Is secondary containment provided for fuel tanks and chemical storage containers?
PERMIT CONDITIONS
1B-19. Does the PWS comply with all special permit conditions relating to surface sources?
SIGNIFICANT DEFICIENCIES
1B-20. Failure to respond to source water contamination issues
A1 Violation - Chapter 109.4, 109.408, 109.701(a)(3)
1B-21. Two or more outages or severe shortages in two consecutive years (excluding statewide drought
emergencies)
B1 Violation - Chapter 109.4, 109.603(d)
1B-22. Any deficiency or combination of deficiencies causing, or having the potential to cause, the
introduction of contamination into the water delivered to consumers
B6 Violation – Chapter 109.4, 109.603(a)
Module 1B
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Surface Sources