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 -1- 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 -2- Surface Sources