Low Pressure Event Form - Grab Samples

Epidemiologic Study of Health Effects Associated with Low Pressure Events in Drinking Water Distribution Systems

G.LPE Form (revised)

Low Pressure Event Form - Grab Samples

OMB: 0920-0960

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Attachment G Form Approved

OMB No. 0920-0960

Exp. 03/31/2016

Utility Name __________________ Utility ID __________________ CDC Event ID________________

Shape1 LOW PRESSURE EVENT FORM

1. Does this event affect at least 10 residential units?Yes (Please continue to question 2)No (This event is not eligible for study)

2. Briefly describe what happened during the event ___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Shape2

c

3. Response ⃝ Planned ⃝ Emergency

3a. When was emergency reported? Date ________Time ___________

4. Event type

4a. What type of break? (mark all that apply) 

Shape3

c20a. What type of water? _____________________________________

Main break (answer 4a and 4b)

Circumferential

Joint

Planned repair

Longitudinal

Split at Corporation

Supply disruption (describe below)

Blowout

Sleeve

_________________________________________

Other _____________________________________________________

Other ___________________________________

_____________________________________________________

5. When did repair/maintenance crew arrive on site?

4b. What factors contributed to the break? (mark all that apply) 

  Date _________________Time _______________

Defective part

Deterioration

6. When was repair/maintenance completed?

Corrosion

Excessive operating pressure

   Date _________________Time _______________

Pumping changes

Water hammer (surge)

7. Main housing type in affected area

Vehicle accident

Contractor main break

Single family homes (detached)

Differential settlement

Temperature change

Duplexes/townhomes (attached)

Other ___________________________________________________

Apartments/condos

8. Location of work site (address)____________________________________

Mobile homes

(cross streets) ______________________ ________________________

Other_______________________________________

(GPS coordinates) (Lat.) _______________ (Long.) ___________________

INFRASTRUCTURE AND WATER INFORMATION

9. Pipe diameter ___________ Inches

13. Soil type (for example, sand, clay, rock backfill)___________________________________

10. Pipe age ___________ Years

14. Pipe interior

11. Pipe depth _____Feet ___Inches

14a. Tuberculation 1 2 3 4 5

12. Pipe material



(smooth) (highly tuberculated)

PVC

Concrete

Asbestos Cement

14b. Describe sediment or biofilm______________________________

Ductile Iron

Cast iron

Wood

__________________________________________________________

Galvanized

HDPE

Steel

15. Source water type ⃝ Surface water ⃝ Groundwater ⃝ Mixed

Don’t know

Other_________________________

16. Name of water storage facility, well, or plant serving area

________________________________________________________________________


Shape4 WATER PRESSURE

17. How was low pressure verified? ⃝ Pressure readings ⃝ Verified at hose bibs (ground-level) ⃝ Customer complaint

Assumed (describe why) ____________________________________________________________________________________

18. Pressure readings

Suggested reading locations

Location of reading

(cross-streets, address, GPS coordinates)

Pressure during event (psi)

Date and time

Pressure after cleanup (psi)

Date and time

Near break/repair

 

 

 

 


Upstream

 

 

 

 

 

Downstream

 

 

 

 

 

REPAIR INFORMATION

19. Was the repair site valved off? ⃝ No ⃝ Completely valved off ⃝ Partially valved off

20. What repair or maintenance activities occurred? (mark all that apply) ⃝ Repair existing main ⃝ Replace existing main

Add new pipes to distribution system ⃝ Fix cross-connection ⃝ Exercise valves ⃝ Flush Hydrant

Cut open main for reasons other than pipe work (for example, install valve) ____________________________________________

Other (describe)__________________________________________________________________________________________

21. What type of repair was conducted? ⃝ Clamp repair ⃝ Cut and replace section of pipe ⃝ Replace or repair fitting

Other (describe)__________________________________________________________________________________________

Shape5

c20a. What type of water? _____________________________________

22. Was the pipe ever submerged in trench water?  ⃝ No ⃝ Yes

22a. Describe water (rain, sewage, leakage from system) _________________________________________________________

23. Describe precipitation while the main was being repaired ⃝ Heavy Rain ⃝ Light Rain ⃝ Snow or Sleet ⃝ None

Shape6

c20a. What type of water? _____________________________________

24. Were any sewage lines near the main being repaired? ⃝ No ⃝ Yes

24a. Describe location, breaches, leaks

_________________________________________________________________________________________________

Shape7

c20a. What type of water? _____________________________________

25. Were any reclaimed water lines near the main being repaired? ⃝ No ⃝ Yes

25a. Describe location, breaches, leaks

_________________________________________________________________________________________________

26. Were replacement parts swabbed prior to being installed? ⃝ Yes ⃝ No ⃝ N/A

27. Was the main flushed before being brought back into service? ⃝ Yes ⃝ No ⃝ N/A

27a. Describe flushing process (for example, estimated velocity and duration) ___________________________________________

28. Was the main chlorinated before being brought back into service? ⃝ Yes ⃝ No ⃝ N/A

  28a. Chlorination method and dose? (slug dose, swabbing, 100 mg/L, 25 mg/L) ________________________________________________________

28b. Disinfectant residual of bulk water in the main before being brought into service? _____________

EVENT IMPACT

29. Number of households that experienced low pressure _______ 29a. Duration of low pressure ______ hrs. ______ min.

Shape8

c20a. What type of water? _____________________________________

30. Was there a loss of household water service?  ⃝ No ⃝ Yes

30a. Num. of households lost service __________

(include total time of loss of service, before and after area valved off)

30b. Duration of lost service ______ hrs. ______ min.

Shape9

c20a. What type of water? _____________________________________

31. Was service to homes turned off? ⃝ No ⃝ Yes

31a. Main lines closed? Service branches to homes closed?

31b. Num. of households out of service__________

31c. Duration of shutoff ______ hrs. ______ min.

32. Was a boil-water advisory (BWA) or notice administered as a result of this event? ⃝ Yes ⃝ No

33. Based on your observations, do you think there was any potential for contamination? ⃝ Yes ⃝ No ⃝ Unsure

33a. Please explain why you selected yes, no, or unsure:____ _____________________________________________________

 __________________________________________________________________________________________________________

 34. Do you have any other comments about the low pressure event? ________________________________________________

 __________________________________________________________________________________________________________

Shape12 Shape10 Shape11

WATER SAMPLE COLLECTION DATA SHEET



SAMPLE ID: ___________________________________ Date & Time: ____________________Collected By: ____________________

Location of sample (address or GPS coordinates): ___________________________________________________________________

Pipe material at service connection: ______________________________ Area: Affected Unaffected

Field water temperature:

oC

Chlorine residual (total or free) (Circle):

mg/L

pH:


Conductivity:

µS/cm

Grab sample collected?

Yes No

Preserved w/ Sodium Thiosulfate?

Yes No

Filtration meter start reading:


Filtration start time:


Filter 100 liters

+ 26.4 gallons =

Filtration end time:


Stop filtration meter reading:


Preserved w/ Sodium Thiosulfate?

Yes No

Shape13 SAMPLE ID: ___________________________________ Date & Time: ____________________Collected By: ____________________

Location of sample (address or GPS coordinates): ___________________________________________________________________

Pipe material at service connection: ______________________________ Area: Affected Unaffected

Field water temperature:

oC

Chlorine residual (total or free) (Circle):

mg/L

pH:


Conductivity:

µS/cm

Grab sample collected?

Yes No

Preserved w/ Sodium Thiosulfate?

Yes No

Filtration meter start reading:


Filtration start time:


Filter 100 liters

+ 26.4 gallons =

Filtration end time:


Stop filtration meter reading:


Preserved w/ Sodium Thiosulfate?

Yes No

Shape14 SAMPLE ID: ___________________________________ Date & Time: ____________________Collected By: ____________________

Location of sample (address or GPS coordinates): ___________________________________________________________________

Pipe material at service connection: ______________________________ Area: Affected Unaffected


Field water temperature:

oC

Chlorine residual (total or free) (Circle):

mg/L



pH:


Conductivity:

µS/cm



Grab sample collected?

Yes No

Preserved w/ Sodium Thiosulfate?

Yes No



Filtration meter start reading:


Filtration start time:




Filter 100 liters

+ 26.4 gallons =

Filtration end time:




Stop filtration meter reading:

____________________

Preserved w/ Sodium Thiosulfate?

Yes No


SIGNATURE:

PRINT NAME:

DATE:

TIME:

SAMPLE CONDITION:

RELINQUISHED BY:

 

 

 

(FOR LAB USE ONLY)

Actual Temperature:

RECEIVED BY:

 

 

 

Received On Ice

Y / N

 


RELINQUISHED BY:

 

 

 

Preserved

Y / N


RECEIVED BY:

 

 

 

Seals Present

Y / N

 


COMMENTS/FIELD OBSERVATIONS:



PLEASE SHIP SAMPLES ON ICE TO KEEP COLD DURING OVERNIGHT SHIPMENT

Container Intact

Y / N



Preserved at Lab

Y / N

 

 

 

Shape17 Shape15 Shape16

WATER SAMPLE COLLECTION DATA SHEET


SAMPLE ID: ___________________________________ Date & Time: ____________________Collected By: ____________________

Location of sample (address or GPS coordinates): ___________________________________________________________________

Pipe material at service connection: ______________________________ Area: Affected Unaffected

Field water temperature:

oC

Chlorine residual (total or free) (Circle):

mg/L

pH:


Conductivity:

µS/cm

Grab sample collected?

Yes No

Preserved w/ Sodium Thiosulfate?

Yes No

Filtration meter start reading:


Filtration start time:


Filter 100 liters

+ 26.4 gallons =

Filtration end time:


Stop filtration meter reading:


Preserved w/ Sodium Thiosulfate?

Yes No

Shape18 SAMPLE ID: ___________________________________ Date & Time: ____________________Collected By: ____________________

Location of sample (address or GPS coordinates): ___________________________________________________________________

Pipe material at service connection: ______________________________ Area: Affected Unaffected

Field water temperature:

oC

Chlorine residual (total or free) (Circle):

mg/L

pH:


Conductivity:

µS/cm

Grab sample collected?

Yes No

Preserved w/ Sodium Thiosulfate?

Yes No

Filtration meter start reading:


Filtration start time:


Filter 100 liters

+ 26.4 gallons =

Filtration end time:


Stop filtration meter reading:


Preserved w/ Sodium Thiosulfate?

Yes No

Shape19 SAMPLE ID: ___________________________________ Date & Time: ____________________Collected By: ____________________

Location of sample (address or GPS coordinates): ___________________________________________________________________

Pipe material at service connection: ______________________________ Area: Affected Unaffected


Field water temperature:

oC

Chlorine residual (total or free) (Circle):

mg/L



pH:


Conductivity:

µS/cm



Grab sample collected?

Yes No

Preserved w/ Sodium Thiosulfate?

Yes No



Filtration meter start reading:


Filtration start time:




Filter 100 liters

+ 26.4 gallons =

Filtration end time:




Stop filtration meter reading:

____________________

Preserved w/ Sodium Thiosulfate?

Yes No


SIGNATURE:

PRINT NAME:

DATE:

TIME:

SAMPLE CONDITION:

RELINQUISHED BY:

 

 

 

(FOR LAB USE ONLY)

Actual Temperature:

RECEIVED BY:

 

 

 

Received On Ice

Y / N

 


RELINQUISHED BY:

 

 

 

Preserved

Y / N


RECEIVED BY:

 

 

 

Seals Present

Y / N

 


COMMENTS/FIELD OBSERVATIONS:



PLEASE SHIP SAMPLES ON ICE TO KEEP COLD DURING OVERNIGHT SHIPMENT

Container Intact

Y / N



Preserved at Lab

Y / N

 

 

 



Public reporting burden of this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0960).


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