ADEM Form 37 "Total Coliform Rule - Level 2 Assessment" - Alabama

What Is ADEM Form 37?

This is a legal form that was released by the Alabama Department of Environmental Management - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2018;
  • The latest edition provided by the Alabama Department of Environmental Management;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of ADEM Form 37 by clicking the link below or browse more documents and templates provided by the Alabama Department of Environmental Management.

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Download ADEM Form 37 "Total Coliform Rule - Level 2 Assessment" - Alabama

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Total Coliform Rule - Level 2 Assessment
ADEM
PWSID:
System Name:
Reviewed
Issue(s)
Corrective Action Taken
Questions
Issue Description
or N/A
(Y/N)
(Including Date)
1. Evaluate sample site.
a. What is the condition of the tap? (Provide comments)
b. What is the location of the tap? (Provide comments)
c. What is the regular use of the connection? (Provide comments)
a. Were there any operation and maintenance activities that could have
introduced total coliforms?
e. Have there been any plumbing breaks or failure? If yes, when?
f. List any identified cross connections after the service connection or in
premise plumbing. (Provide comments)
g. Were all the backflow prevention devices present, operational, and
maintained?
h. Were there any low pressure events or changes in the water pressure after
the service connection or in the premise plumbing? If yes, when?
i. Are there any treatment devices after the service connection or in premise?
Point of Entry (POE)
Point of Use (POU)
(Circle response, if applicable)
j. Other comments on sample site?
2. Sample protocol followed and reviewed.
a. Flush tap, disinfect tap (flame, chlorine etc.), remove aerator, no swivel,
fresh sample bottles and sample storage acceptable.
3. Have any of the following occurred at relevant facilities prior to the
collection of TC samples?
a. Were there any operation and maintenance activities that could have
introduced total coliforms?
b. Have there been any interruptions in the treatment process?
c. Has the system lost pressure to less than 5 psi?
d. Have there been any vandalism and/or unauthorized access to the facilities?
e. Are there any visible indicators of unsanitary conditions observed?
1
ADEM Form #37 XX/18 m2
Total Coliform Rule - Level 2 Assessment
ADEM
PWSID:
System Name:
Reviewed
Issue(s)
Corrective Action Taken
Questions
Issue Description
or N/A
(Y/N)
(Including Date)
1. Evaluate sample site.
a. What is the condition of the tap? (Provide comments)
b. What is the location of the tap? (Provide comments)
c. What is the regular use of the connection? (Provide comments)
a. Were there any operation and maintenance activities that could have
introduced total coliforms?
e. Have there been any plumbing breaks or failure? If yes, when?
f. List any identified cross connections after the service connection or in
premise plumbing. (Provide comments)
g. Were all the backflow prevention devices present, operational, and
maintained?
h. Were there any low pressure events or changes in the water pressure after
the service connection or in the premise plumbing? If yes, when?
i. Are there any treatment devices after the service connection or in premise?
Point of Entry (POE)
Point of Use (POU)
(Circle response, if applicable)
j. Other comments on sample site?
2. Sample protocol followed and reviewed.
a. Flush tap, disinfect tap (flame, chlorine etc.), remove aerator, no swivel,
fresh sample bottles and sample storage acceptable.
3. Have any of the following occurred at relevant facilities prior to the
collection of TC samples?
a. Were there any operation and maintenance activities that could have
introduced total coliforms?
b. Have there been any interruptions in the treatment process?
c. Has the system lost pressure to less than 5 psi?
d. Have there been any vandalism and/or unauthorized access to the facilities?
e. Are there any visible indicators of unsanitary conditions observed?
1
ADEM Form #37 XX/18 m2
Total Coliform Rule - Level 2 Assessment
ADEM
PWSID:
System Name:
Reviewed
Issue(s)
Corrective Action Taken
Questions
Issue Description
or N/A
(Y/N)
(Including Date)
f. Have there been any analytical results or any additional samples collected,
1. Evaluate sample site.
including source water samples which were positive (not for compliance)?
g. Have there been any community illness suspected of being waterborne (e.g.
Does the community public health official indicate that an outbreak has
occurred)?
h. Did the water system receive any TCR monitoring violations in the past 12
months? If yes, when.
Date:
i. What was the most recent date on which satisfactory total coliform samples
were taken?
j. Has there been a fire fighting event, flushing operation, sheared hydrant,
etc?
k. Other comments on records and maintenance?
4. Recent operational changes to the system
a. Have any inactive sources recently been introduced into the system?
b. Have there been any new sources introduced into the system?
c. Is there evidence of any potential sources of contamination (main breaks,
low pressure, high turbidity, loss of disinfection, etc)?
5. Distribution System
a. System pressure: Is there evidence that the system experienced low or
negative pressure? If yes, when?
b. List any identified cross connections.
c. Pump station: Are there any sanitary defects in the pump station? Are
pump(s) operable?
d. Last pump maintenance/service date?
e. Air relief valves: Is the valve vault subject to flooding or does the vent
terminate below grade?
f. Fire hydrant/blow off: Are any located in an area with a high water table or
pits?
g. Is the distribution system secured to prevent unauthorized access?
2
ADEM Form #37 XX/18 m2
Total Coliform Rule - Level 2 Assessment
ADEM
PWSID:
System Name:
Reviewed
Issue(s)
Corrective Action Taken
Questions
Issue Description
or N/A
(Y/N)
(Including Date)
h. Are the backflow prevention devices at high risk sites present, operational
1. Evaluate sample site.
and maintained?
i. Have there been any water main repairs or additions? If yes, when and what
was the repair or addition?
j. Have there been any water main breaks? If yes, when?
k. Was there any scheduled flushing of the distribution system? If yes, when?
l. Is there any evidence flushing of intentional contamination in the
distribution system?
m. Other comments on the distribution system.
6. Storage Tank
a. Are the overflow and vents properly screened?
b. Is the facility secured to prevent unauthorized access?
c. Does the access opening have the proper gasket and sealed tightly?
d. Could the physical condition of the tank be a source of contamination?
e. Is the vent turned down and maintaining an approved air gap at the
termination point?
f. Does the drain/overflow line terminate at a minimum of 12" air gap?
g. If present, is the pressure tank maintaining an appropriate minimum
pressure?
h. Has proper O&M been preformed?
i. Was there any observed physical deterioration of the tank?
j. Were there any observed leaks?
k. Is there any evidence of intentional contamination at the storage tank?
l. Has there been any facility maintenance (i.e. painting/coating)? If yes,
when?
m. Is the facility maintenance occurring on a regular schedule?
3
ADEM Form #37 XX/18 m2
Total Coliform Rule - Level 2 Assessment
ADEM
PWSID:
System Name:
Reviewed
Issue(s)
Corrective Action Taken
Questions
Issue Description
or N/A
(Y/N)
(Including Date)
n. Does the tank "float" on the distribution system or are there separate inlet
1. Evaluate sample site.
and outlet lines?
o. What is the measured chlorine residual (total/free) of the water exiting the
storage tank today?
p. Are there any unsealed openings in the storage facility such as access
doors, vents or joints?
q. Other comments on the storage tank(s).
7. Treatment Process
a. Are treatment devices operational and maintained?
b. Is there any recent changes installation or repair of the treatment
equipment?
c. Were there any recent changes in the treatment process? If yes, when and
what was changed?
d. Were there any interruptions of treatment (lapses in chemical feed,
turbidity excursions, disinfection)? If yes, which part, when and for how long?
e. What is the free chlorine residual measured immediately downstream from
the point of application?
f. Did a review of the filter turbidity profiles reveal any anomalies?
g. Were all the backflow prevention devices present, operational, and
maintained?
h. Were the flow rates above the rated capacity?
i. Were there anomalies on the settled water turbidities?
j. Other comments on the treatment process.
4
ADEM Form #37 XX/18 m2
Total Coliform Rule - Level 2 Assessment
ADEM
PWSID:
System Name:
Reviewed
Issue(s)
Corrective Action Taken
Questions
Issue Description
or N/A
(Y/N)
(Including Date)
8. Source - Well
1. Evaluate sample site.
a. Is the sanitary seal intact?
b. Is the vent screened?
c. Does the vent and pump to waste terminate in an approved air gap?
d. Are there any unprotected cross connections at the wellhead?
e. How is the well used?
Primary
Backup
Emergency
Not a PWS
Not Drinking Water
(Circle if applicable)
Height:
Comments:
f. How far does the casing extend above grade?
g. Is the well cap vented?
h. Is there evidence of standing water near the wellhead?
i. Is the wellhead secured to prevent unauthorized access?
j. Have there been any sewer spills, source water spills or other disturbances
in the immediate area?
k. Other comments on the well source. (Are there aspects of well construction
and operation that would affect bacteriological positives?)
9. Source - Spring
a. What is the condition of the spring box development?
b. What is the condition of the spring box?
c. Is the spring secured to prevent unauthorized access?
d. Other comments on the spring source.
10. Source - Surface Water Supply
a. Have there been any sewer spills, source water spills or other disturbances?
b. Have there been any algal blooms?
c. Has source water turnover occurred?
d. Other source water comments.
5
ADEM Form #37 XX/18 m2
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