ETA 6-38 Inspection of Water and Supply Facilities

OJC 6-38

OMB Control Number: 1205-0219
Expires: xx/xx/xxxx

JOB CORPS ENVIRONMENTAL HEALTH PROGRAM

INSPECTION OF WATER SUPPLY FACILITIES
_______________________________________________________
Center Name

________________________________________________________________
Center Director

_________________________________________

________________________________________________

Center Address

Year/Quarter (for example, 2008/1 QTR)

This inspection report is not required of centers utilizing a state-approved municipal supply. Indicate nature of facilities by checking below all that apply:

√ WATER TREATMENT

√ WATER INTAKE
1.
2.
3.
4.

Well
Infiltration gallery
Spring collection box
Surface water intake, lake, stream, or reservoir

ITEM
WATER SOURCE
13. Raw water source has no known sources of pollution
WATER COLLECTION FACILITY
14. Sanitary construction and closed to insects and animals

4

2
5
4
4
3

23. Unit operating efficiently

2

24. Settled sludge disposed of in approved manner

1
2
3
5
2
3
7

*31. Meets bacteriological requirement

9

PHYSICAL TEST
32. Color less than limit of 15 units

3

Total Score +:

COMMENTS

2

COAGULATION AND SETTLING
22. Records kept on daily use of chemicals

*33. Turbidity less than limit of 1 unit
*34. Finished water meets EPA standards for all
chemicals and parameters
35. Adequate chlorine in the distribution system
STORAGE
36. Capable of holding one day’s consumption plus
emergency needs
37. Condition good; water-tight construction

Chlorination
Activated carbon
No treatment
Other (Explain)

4
4

*27. No cross connections or back-siphonage possible
28. Adequate pressure of 20 psi under maximum draft
conditions at outlets
29. No leakage or possible contamination in distribution
system
BACTERIOLOGICAL EXAMINATION
*30. Frequency of bacteriological testing at least monthly

9.
10.
11.
12.

4

16. Pumping equipment of water-tight construction

FILTRATION
25. Unit cleaned regularly and in good repair
PLUMBING
26. Non-potable water piping identified

Screens
Settling
Coagulation with chemicals
Filtration

WT.

15. Protected from surface wash and flooding
CHLORINATION FACILITY
17. Completely enclosed, locked, clean, and in good repair
18. Approved automatic chlorinator with gas mask (for
gaseous system)
*19. Checked daily for proper operation
20. Free chlorination residuals measured daily, and daily
log of chlorine residuals kept
21. Chlorine residual on day of inspection adequate

5.
6.
7.
8.

5
10
5
4
3

/ 100

The items circled above are violations found on this date and must be corrected by next inspection or earlier.
*Critical items requiring immediate corrective action by Center Director
+A score less than 100 requires follow-up correspondence from the Center Director to the National Office of Job Corps and Regional
Office with this inspection report detailing necessary corrective action and proposed schedule for completion.
Inspection Date: __________________________________

Inspected By:

____________________________________

Agency or Company: ______________________________
I, the Center Director or designee, have received a copy of this report and understand its contents.
__________________________________________________________________________________
SIGNED

TITLE

FORWARD SCANNED FORM AND CORRECTIVE
ACTION WITHIN 7 DAYS OF INSPECTION TO:
U.S. Department of Labor/Office of Job Corps
E-mail: [email protected]

OJC 6-38
June 2008

INSPECTION OF WATER SUPPLY FACILITIES

1.

Purpose. The purpose of this form is to provide Job Corps with a quarterly record of the
performance and health evaluation of Job Corps centers’ water supply facilities. This
inspection report is not required of centers utilizing a state-approved municipal supply that
satisfies the latest National Primary Drinking Water Regulations (NPDWRs).

2.

Originator. This form is completed by an appropriate representative of an authorized
public health agency or another qualified environmental health specialist, other than
center-related personnel, selected by the Center Director.

3.

Frequency. Quarterly by December 31, March 31, June 30, and September 30, and any
additional time that conditions may warrant.

4.

Distribution. This form may or may not be a multi-copy form. The original copy is
retained by the center for action purposes. The original should be scanned and forwarded
via e-mail to (1) the National Office of Job Corps, (2) the Regional Office of Job Corps, (3)
agency or contractor operator office, and (4) the contracted inspector, if requested.

5.

General Instructions. This form consists of two pages—an inspection form and
instructions. Each item of the inspection form should be completed by the authorized
person performing the inspection.

6.

Detailed Instructions.
a.
Indicate deficiencies by marking the WT. column (circle, “x” out, etc., the numerical
weight) and providing an explanation in the comments column.
b.
The full weighted value of an item found to be deficient will be subtracted from the
total score. An explanation of exactly what was wrong should be provided by the
inspector. If comments do not fit in the space provided, additional sheets may be
attached to the form.

7.

Disposition. Each recipient of this form is to maintain it on file for a period of 3 years, and
then destroy.

Public Burden Statement: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control
number and expiration date. Public reporting burden for this collection of information, which is required to obtain or retain benefits (29 USC
2881), is estimated to average 75 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. This information collection is for program
management and Congressional reporting purposes. Send comments regarding this burden estimate or any aspect of this collection of
information, including suggestions for reducing the burden, to the U.S. Department of Labor, Office of Job Corps, Room N-4507, Washington, D.C.
20210 (Paperwork Reduction Project 1205-0219).