ETA 6-38 Inspection of Water Supply Facilities

U.S. Department of Labor Employment and Training Administration Office of Job Corps

ETA FORM 6-38 OMB Control No. 1205-0219 Expiration Date: 05/31/2025

Job Corps Environmental Health Program: Inspection of Water Supply Facilities

Purpose of this form: The form provides Job Corps with a quarterly record of the performance and health evaluation of Job Corps centers’ water supply facilities.

Center Name:		Center Director:	Enter information here
Center Address:	Enter information here	Year/Quarter (for example, 2008/1 QTR):	Enter information here

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 Intake		√ Water Treatment
1. Well	☐	5. Screens	☐	9. Chlorination	☐
2. Infiltration gallery	☐	6. Settling	☐	10. Activated carbon	☐
3. Spring collection box	☐	7. Coagulation with chemicals	☐	11. No treatment	☐
4. Surface water intake, lake, stream, or reservoir	☐	8. Filtration	☐	12. Other	☐

Item	WT.	Comments
Water Source
13. Raw water source has no known sources of pollution	4	Enter information here
Water Collection Facility
14. Sanitary construction and closed to insects and animals	4	Enter information here
15. Protected from surface wash and flooding	4	Enter information here
16. Pumping equipment of water-tight construction	4	Enter information here
Chlorination Facility
17. Completely enclosed, locked, clean, and in good repair	2	Enter information here
18. Approved automatic chlorinator with gas mask (for gaseous system)	2	Enter information here
*19. Checked daily for proper operation	5	Enter information here
20. Free chlorination residuals measured daily, and daily log of chlorine residuals kept	4	Enter information here
21. Chlorine residual on day of inspection adequate	4	Enter information here
Coagulation and Settling
22. Records kept on daily use of chemicals	3	Enter information here
23. Unit operating efficiently	2	Enter information here
24. Settled sludge disposed of in approved manner	1	Enter information here
Filtration
25. Unit cleaned regularly and in good repair	2	Enter information here
Plumbing
26. Non-potable water piping identified	3	Enter information here
*27. No cross connections or back-siphonage possible	5	Enter information here
28. Adequate pressure of 20 psi under maximum draft conditions at outlets	2	Enter information here
29. No leakage or possible contamination in distribution system	3	Enter information here
Bacteriological Examination
*30. Frequency of bacteriological testing at least monthly	7	Enter information here
*31. Meets bacteriological requirement	2	Enter information here
Physical Test
32. Color less than limit of 15 units	3	Enter information here
*33. Turbidity less than limit of 1 unit	5	Enter information here
*34. Finished water meets EPA standards for all chemicals and parameters	10	Enter information here
35. Adequate chlorine in the distribution system	5	Enter information here
Storage
36. Capable of holding one day’s consumption plus emergency needs	4	Enter information here
37. Condition good; water-tight construction	3	Enter information here

Total Score⁺: / 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:	Enter information here	Inspected By:	Enter information here
Agency or Company:	Enter information here

I, the Center Director, or designee, have received a copy of this report and understand its contents.
Title
SIGNATURE:		DATE: Click or tap to enter a date.

FORWARD SCANNED FORM AND CORRECTIVE

ACTION WITHIN 7 DAYS OF INSPECTION TO:

U.S. Department of Labor/Office of Job Corps OJC 6-38

E-mail: [email protected] 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.

   1. Indicate deficiencies by marking the WT. column (circle, “x” out, etc., the numerical weight) and providing an explanation in the comments column.

   2. 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.

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