Ohio EPA, DDAGW Level 1 Assessment Form (Final 9/22/2016)
System Name: / Source Water: / [ ] / PWS ID#:System Type: / [ ] / Pop. Served: / PWS Address:
PWS Contact or ORC: / Phone:
Person collecting total coliform samples: / Phone:
Ohio EPA staff person: / Phone: / County:
Date Assessment Completed: / Date(s) Revised (if applicable): / District: / [ ]
/ Assessment Elements / Y / N / N/A / Issue Description/Comments
(Indicate Assessment Element number being described) / Corrective Action Taken/Planned
and Date Completed/Due /
1. / Source – Well
1.1. / Well cap is acceptable & secure?
1.2. / Well casing in good condition?
1.3. / Any ponding around well? (heavy rainfall/flooding)
1.4. / Vent appropriately screened?
1.5. / Any cross connections?
1.6. / Pump to waste line air gap acceptable?
2. / Source – Surface Water Supply
2.1. / Recent heavy rainfall, flooding, rapid snowmelt?
2.2. / Any sewage discharges?
3. / WTP Components/Treatment Process Changes or Upsets (Includes treatment equipment, bladder and pressure tanks)
3.1. / Interruptions or maintenance of any components?
4. / Distribution System Issues (Past or Present)
4.1. / System pressure low or negative due to break/repair?
4.2. / Cross connections? Dead ends?
4.3. / Pump station or air relief valve issues?
4.4. / Fire hydrants or blow off?
5. / Storage Tanks
5.1. / Tank condition and screens acceptable?
5.2. / Vent, drain overflow and pressure are acceptable?
5.3. / Secured from unauthorized access?
5.4. / Access opening has proper seal?
6. / Total Coliform Sample Site1
6.1. / Acceptable location and tap condition?1
6.2. / Describe regular use of connection1
7. / Sampling Protocol1
7.1. / Tap disinfected, flushed, and aerator removed?1
7.2. / Sample bottles fresh & sample storage acceptable?1
8. / Recent Operational Changes
8.1. / New/different source of water?
8.2. / Recent operational changes?
8.3. / Potential sources of contamination?
8.4. / Recent start-up completed by seasonal system?
9. / System Upset Prior to Sample Collection
9.1. / Maintenance that could have caused contamination?
9.2. / Vandalism or unauthorized access to facilities?
9.3. / Unsanitary conditions?
9.4. / Firefighting, flushing, hydrant shearing events?
9.5. / Water quality parameters out of norm?
Note: Form must be completed based on data and documents available to the PWS or operator in charge. The public water system shall maintain a copy on file and the original shall be returned to the Ohio EPA within 30 days of being notified that a Level 1 Assessment was triggered (See OAC rule 3745-81-53).
Additional Comments (Include a proposed timetable for completing corrective actions, if applicable, or indicate if no corrective actions are required):
Name of person completing the form (PRINTED): / Title:
Reserved for Ohio EPA Review (Use only when PWS conducts assessment) / Yes / No / Comments
1. Has assessment been successfully completed?
2. Likely reason for TC+ occurrence has been found
3. PWS has corrected the problem or has an approved corrective action plan
4. Name of Ohio EPA reviewer
1Any issues related to the sample site or sampling protocol should be entered into the SDWIS “Site Visit” as a minimum deficiency.
Page 2 of 2