Form 0920-0960 Customer Contact Questionnaire

Attachment Q Form Approved

OMB No. 0920-0960

Exp. Date 03/31/2016

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

E-mail

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

Please attach additional sheets as necessary.

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).