Low Pressure Event Form - Ultrafilter and Grab Samples

Attachment G Form Approved

OMB No. 0920-0960

Exp. 03/31/2016

Utility Name __________________ Utility ID __________________ CDC Event ID________________

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 ___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
c 3. Response ⃝ Planned ⃝ Emergency				3a. When was emergency reported? Date ________Time ___________
4. Event type				4a. What type of break? (mark all that apply)
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
			________________________________________________________________________

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)__________________________________________________________________________________________
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
c20a. What type of water? _____________________________________ 24. Were any sewage lines near the main being repaired? ⃝ No ⃝ Yes					24a. Describe location, breaches, leaks
_________________________________________________________________________________________________
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.
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.
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? ________________________________________________
__________________________________________________________________________________________________________

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

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

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

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

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

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).