Utility Name ___________________________ EventID _____________________
Characteristics of the exposed area(s) (mark all that apply)
Water service disruption caused by LPE
Smaller diameter mains nearby or in direct hydraulic connection to LPE
Dead-end mains nearby or in hydraulic connection to LPE
No alternative feeds to compensate for lower pressure caused by LPE; area hydraulically isolated
Away from PRVs, pumps, or storage facilities that float on the system, which would allow water to be released into the system to compensate for lower pressure caused by LPE
Higher elevation than main break location (assuming there is no nearby storage to compensate for the elevation)
Known lower steady state pressures
Near lower flow areas such as dead ends, pressure zone boundaries, high elevations
Other (for example, pump station activity caused drop in water pressure in the area before the event ____________________________________________________________________________________________
Characteristics of the unexposed area(s) (mark all that apply)
Upstream of the LPE
Nearby but different pressure zone
No recent main breaks or LPEs in the vicinity
If in same pressure zone, served by pump or storage facility that floats on system
If in same pressure zone, area served by larger diameter mains with routinely good steady state pressures
Areas in the middle of the grid (away from low flow sections, dead ends, pressure zone boundaries)
Lower elevation than main break
Other (for example, exposed area was hydraulically isolated; there were no alternative feeds to exposed area, so no additional areas were impacted by the LPE) ____________________________________________________________________________________________________________________________________
Describe characteristics of exposed (LPE areas) and unexposed areas. Include event hydraulic map and description below.
Event Hydraulic Map showing final selection of exposed and unexposed areas. Maps can be hand-drawn or computer-generated and should help explain the reasoning behind the choice of the study areas. Include location of water source(s), normal flow direction, pipe diameters, flow direction during event (if change), location of break or origin of low pressure, valved-off areas, low pressure (exposed) areas, unaffected (unexposed) areas.
Description – Briefly describe the cause and duration of low pressure and justify the choice of the study areas.
Utility Customer Information
Area |
Last Name |
First Name |
Mailing House |
Mailing Street |
Mailing Supp. |
Mailing City |
Mailing State |
Mailing Zip |
Premise House |
Premise Street |
Premise Supp. |
Premise City |
Premise State |
Phone |
Premise zip |
|
Exposed |
Smith |
Jon |
123 |
Main St |
Unit B |
Atlanta |
GA |
30033 |
123 |
Main St |
Unit B |
Atlanta |
|
GA |
|
30033 |
Exposed |
Doe |
Jane |
PO Box |
12345 |
|
Atlanta |
GA |
30033 |
1254 |
Main St. |
|
Atlanta |
|
GA |
|
30033 |
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Please attach additional sheets as necessary. |
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Public reporting burden of this collection of information is estimated to average 3 hours 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).
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | CDC User |
File Modified | 0000-00-00 |
File Created | 2021-01-20 |