"Chemical Feed System Project Application" - Connecticut

Chemical Feed System Project Application is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

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STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
DRINKING WATER SECTION
CHEMICAL FEED SYSTEM PROJECT APPLICATION
Instructions
This application is provided in the interest of facilitating the approval process for chemical feed system projects
and must be submitted to the Department of Public Health (DPH) along with a General Application Form. A
document entitled “Liquid Chemical Feed System Design and Installation Guidelines” is available on the DPH
website
http://www.ct.gov/dph/publicdrinkingwater
for use as a reference in the design of a chemical feed
system and identifies applicable Regulations of Connecticut State Agencies (RCSA) or Connecticut General
Statutes (CGS). If feed systems are being proposed for separate chemicals, a separate application for each
system needs to be completed. Additional supporting information as identified with an asterisk (*) in this
application will need to be provided unless indicated otherwise. Specific and applicable RCSA or CGS will be
stated within brackets [ ]. If the project overall has multiple components other than a chemical feed system (i.e.
wells, tanks, pumps, etc.) additional applications may need to be submitted. Check off all items that apply.
Section A. General Information
PWS Name:
PWSID #: CT
Please provide the contact information of the primary person who can answer technical questions regarding this
project:
Name:
Title:
Company:
Address:
Phone Number:
Fax Number:
E-mail Address:
Section B. Chemical Information
1. Purpose for use of chemical
Disinfection (i.e. sodium hypochlorite, etc.)
Fluoridation (i.e. hydrofluorosilicic acid, etc.)
pH adjustment (i.e. sodium hydroxide, etc.)
Oxidation (i.e. sodium hypochlorite, potassium
Corrosion Control (i.e. polyphosphate,
permanganate, etc.)
hexametaphosphate, etc.)
filter aid (i.e. polymer)
Coagulation (i.e. ALUM, ferric chloride, etc.)
Other:
rev 06.13.2012
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Chemical Feed System Project Application
STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
DRINKING WATER SECTION
CHEMICAL FEED SYSTEM PROJECT APPLICATION
Instructions
This application is provided in the interest of facilitating the approval process for chemical feed system projects
and must be submitted to the Department of Public Health (DPH) along with a General Application Form. A
document entitled “Liquid Chemical Feed System Design and Installation Guidelines” is available on the DPH
website
http://www.ct.gov/dph/publicdrinkingwater
for use as a reference in the design of a chemical feed
system and identifies applicable Regulations of Connecticut State Agencies (RCSA) or Connecticut General
Statutes (CGS). If feed systems are being proposed for separate chemicals, a separate application for each
system needs to be completed. Additional supporting information as identified with an asterisk (*) in this
application will need to be provided unless indicated otherwise. Specific and applicable RCSA or CGS will be
stated within brackets [ ]. If the project overall has multiple components other than a chemical feed system (i.e.
wells, tanks, pumps, etc.) additional applications may need to be submitted. Check off all items that apply.
Section A. General Information
PWS Name:
PWSID #: CT
Please provide the contact information of the primary person who can answer technical questions regarding this
project:
Name:
Title:
Company:
Address:
Phone Number:
Fax Number:
E-mail Address:
Section B. Chemical Information
1. Purpose for use of chemical
Disinfection (i.e. sodium hypochlorite, etc.)
Fluoridation (i.e. hydrofluorosilicic acid, etc.)
pH adjustment (i.e. sodium hydroxide, etc.)
Oxidation (i.e. sodium hypochlorite, potassium
Corrosion Control (i.e. polyphosphate,
permanganate, etc.)
hexametaphosphate, etc.)
filter aid (i.e. polymer)
Coagulation (i.e. ALUM, ferric chloride, etc.)
Other:
rev 06.13.2012
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Chemical Feed System Project Application
Section B. Chemical Information (continued)
Manufacturer:
2. Chemical
Trade name:
liquid
dry
Chemical name:
Delivery Container:
5 gal. carboy
bags(#):
Chemical strength (percent):
55 gal. drum
bulk delivery
Other:
The DPH accepts the use of a drinking water treatment chemical which is certified to ANSI/NSF Standard 60.
ANSI/NSF Standard 60 is a national industry standard pertaining to the certification of drinking water treatment
chemicals. There are third party accredited testing laboratories including, but not limited to: NSF (www.nsf.org),
UL (www.ul.com), and WQA (www.wqa.org) which certify drinking water treatment chemicals to ANSI/NSF
Standard 60. [RCSA Section 19-13-B80]
* A copy of a document identifying NSF Standard 60 listing for chemical proposed is provided.
Yes
No
Section C. Plans and Specifications
* 1. Scaled project plan sheet(s) or accurate construction drawing(s)/schematic(s) of the proposed chemical feed
system and its location relative to applicable existing facility components needs to be submitted to the DPH. As a
minimum the following components, if applicable, should be shown and labeled: bulk storage tank, tank fill line,
transfer pump(s), day tank, chemical metering pump(s), feed line, carrying and/or make-up water pipe, point of
chemical injection, secondary containment, flow switch, sample taps, isolation valves, etc.
2. Copy of contract bid specifications and/or manufacturers’ specifications/cut sheets for major project
components identified in this application, if already selected for installation, should be submitted.
3. A new treatment plant facility/structure must be located above the level of a 100 year flood. [RCSA Section 19-
13-B102(d)(1)(A)]
* Verification must be provided (FEMA map or other).
Section D. Sources to be Treated and Design Flow Rate
Identify sources and/or facility, as may be applicable, at which treatment is to be installed:
Existing or Proposed Water Treatment Plant Name:
Surface water supply; and name:
Wells: number(s) and/or name(s):
Maximum design flow rate (gpm):
Section E. Feed System Components
*
1. Bulk Storage Tank(s)
Level measuring:
gal. incr.
lb. scale
No. of tanks:
Level sensor
Site glass
Volume (gallons):
Other:
Material of tank:
Secondary Containment provided:
Yes
No
Covered:
Yes
No
Fill port:
Yes
No
Locked:
Yes
No
Vented to outside:
Yes
No; If yes, is the vent
Labeled as to chemical stored:
Yes
No
shielded, screened and not located near ventilation air
intake?
Yes
No
Are bulk tanks sized to provide at least a 30 day supply
of chemical?
Yes
No
rev 06.12.2012
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Chemical Feed System Project Application
Section E. Feed System Components (continued)
*
2. Day Tank(s)
Level measuring:
gal. incr.
lb. scale
No. of tanks:
Level sensor
Site glass
Volume (gallons):
Other:
Material of tank:
Secondary Containment provided:
Yes
No
Covered:
Yes
No
Labeled as to chemical stored:
Yes
No
Vented to outside:
Yes
No; If yes, is the vent
Are day tanks sized to provide no more than a 30 hour
shielded, screened and not located near ventilation air
supply of chemical?
Yes
No
intake?
Yes
No
3. Chemical Transfer (bulk storage tank to day tank)
Gravity:
Yes
No Transfer pump(s):
Yes
No If yes, No. of pumps:
Deadman switch/valve provided:
Yes
No
*
No. of pumps:
4. Chemical Metering Pump(s)
Proposed dosage rate of chemical (mg/L):
Capacity of each pump (gals. per hr.):
Were metering pumps sized to provide adequate chemical dosage at maximum flow rate?
Yes
No
Pacing/activation of pump:
well pump start
booster pump start
flow switch
proportional to flow (4-20
mA meter signal)
Other:
Controls provided for manual, off or automatic operation (HOA) of pump (s):
Yes
No
Anti-Siphon protection on metering pump or feed line:
Yes
No
Four Function Valve:
Yes
No
* Are calculations used for sizing of bulk storage tank(s), day tank(s) and chemical metering pump(s) per Section
E, items 1, 2 and 4 provided?:
Yes
No
5. Point of Chemical Injection and Chemical Feed Lines:
Well discharge pipe
Blended wells discharge pipe
Prior to press. tank(s)
Prior to atmospheric
tank(s)
Prior to filter unit(s)
Other:
Chemical feed line: Check valve provided:
Yes
No Injection nozzle provided:
Yes
No
Chemical feed line(s) clearly labeled or color coded as to chemical in pipe:
Yes
No
6. Cross Connection Protection - Solution Make-up Water/Carrying Water Line [Section 19-13-B38 of RCSA]
Protection of solution make-up water supply for day tank:
Hard piped with air gap
Hose bib atmospheric
vacuum breaker
Other:
Protection of carrying water line:
RPD provided
Other:
7. Sampling Taps (smooth nosed and free of obstructions): [RCSA Section 19-13-B102]
Raw water (each source/well and prior to any treatment):
Yes
No
Point of Entry (required for compliance monitoring/after all treatment prior to distribution):
Yes
No
rev 06.12.2012
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Chemical Feed System Project Application
Section E. Feed System Components (continued)
8. Testing (Labs, Test Kits, Analyzer and/or Recorder) [RCSA Section 19-13-B102(g)]
Water samples taken for compliance monitoring must be analyzed and reported by a lab approved by the DPH.
Identify test parameter required for monitoring with the use of proposed chemical:
chlorine residual
pH
phosphate
fluoride
Are tests for parameter to be conducted by State Certified Laboratory?:
Yes
No
If yes, CT approved Lab: PH -
The DPH may grant an exemption from the use of laboratory when the analysis for the parameter is conducted by
a CT certified treatment operator using a test kit or continuous analyzer conforming to a test methodology
approved by the DPH. A list of methodologies approved by the DPH can be obtained upon request.
Is a test kit or analyzer to be used for compliance monitoring?:
Yes
No
If yes, test parameter:
Test kit - Manufacturer/Model No.:
Testing Methodology:
Analyzer - Manufacturer/Model No.:
Testing Methodology:
CT certified treatment plant operator who will use and maintain test kit and/or analyzer:
Name:
CT Certification #:
* A treatment plant operator must be identified and documentation from the manufacturer of test kit or analyzer as
to its testing methodology must be provided to DPH before an exemption can be
considered.
Method to retain test results from analyzer:
Written log
Chart recorder
SCADA
Other:
9. Controls and Alarms:
Are high level alarms provided on bulk tank?
Yes
No; on day tank?
Yes
No
Are alarms to be provided for test parameter being monitored by the continuous analyzer?:
Yes
No
If yes, check all applicable. Alarms:
low level
high level Alarm Type:
audio
visual
dialer
SCADA
Other
Will analyzer high level alarm initiate shut down of chemical metering pump?:
Yes
No
10. Safety
Material Safety Data Sheets (MSDS) for chemical proposed to be kept at treatment facility:
Yes
No
Safety equipment to be provided at treatment facility:
eyewash;
shower
other:
Section F. Water Treatment Plant/Operators (only Community and NTNC systems)
* For all new chemical treatment additions or modifications a “Water Treatment Plant Classification Form” and
“Operator Verification Form” must be submitted. [RCSA Sections 25-32-8 and 25-32-9, respectively] These forms
can be downloaded from the DPH’s website. A Transient Non-Community (TNC) water system does not have to
complete these forms.
An Operator Verification Form is not needed where the system is currently operated by an individual holding a
Water Treatment Plant Operator Certification at or above the proposed treatment plant classification level.
rev 06.12.2012
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Chemical Feed System Project Application
Section G. Disinfection CT for a Chlorine Feed System
[RCSA Section 19-13-B102(e)(7)(M)] When a groundwater source/well not under the direct influence of surface
water is chlorinated, a free chlorine residual of a least 0.2 mg/L after 10 minutes of contact, or the equivalent
thereof, shall be used. CT therefore is 2 mg-min/L (0.2 mg/L x10 min).
The Ground Water Rule, which became effective December 1, 2009, allows a water system to operate a system
for disinfecting water which will achieve 4-log inactivation of viruses to avoid the requirement to conduct triggered
and/or assessment source/well water monitoring. The rule may also require 4-log inactivation of viruses if a
system has a confirmed fecal indicator (E.Coli bacteria) present in its well water and physical corrective actions
implemented have been unable to resolve the E. Coli contamination. A CT value of at least 6 mg-min/L (minimum
residual chlorine concentration of 0.2 mg/L x 30 min or equivalent) must be maintained before or at the first
customer/consumer and at a corresponding compliance sample location to demonstrate 4-log inactivation of
viruses. “TECHNICAL GUIDELINES FOR DETERMINING DISINFECTION “CT” WHEN USING CHLORINE FOR
DISINFECTION OF GROUNDWATER SOURCES OF SUPPLY” is available on the DPH website to assist in
determining CT.
Does the proposed project include modifications to an existing chlorination system, point of chlorine injection,
facility piping, etc. that would change CT, or is chlorination system being added to a system or water treatment
plant which is currently does not chlorinate?
Yes
No
If yes, a separate DISINFECTION “CT” APPLICATION FOR A GROUNDWATER USING CHLORINE FOR
DISINFECTION, available on the DPH website, must be submitted.
Section H. Certification
This application must be signed by the PWS administrative official, his/her authorized representative, or certified
operator of the PWS.
I hereby certify that I have examined the information contained in this application as submitted to the DPH and
have determined it to be accurate to the best of my knowledge:
Signature:
Date Signed:
Name (Print):
Telephone #:
Title and Relationship to PWS:
rev 06.12.2012
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Chemical Feed System Project Application
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