"Capacity Assessment/Inspection Forms for Non-transient Non-community Systems" - Mississippi

Capacity Assessment/Inspection Forms for Non-transient Non-community Systems is a legal document that was released by the Mississippi Department of Health - a government authority operating within Mississippi.

Form Details:

  • Released on July 3, 2019;
  • The latest edition currently provided by the Mississippi Department of Health;
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Download "Capacity Assessment/Inspection Forms for Non-transient Non-community Systems" - Mississippi

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Generated October 3, 2019, 10:55 AM CST.
NON-TRANSIENT, NON-COMMUNITY FORM
Mississippi Department of Health
Bureau of Public Water Supply
FY 2020 Public Water System Capacity Assessment Form
NOTE: This form must be completed whenever a routine sanitary survey of a public water system is conducted by a
regional engineer of the Bureau of Public Water Supply
PWS ID#:
Class:
Survey Date:
County:
Public Water System:
Conn:
Certified Waterworks Operator:
Pop:
CAPACITY RATING DETERMINATION
Technical (T) Capacity Rating: [
]
Managerial (M) Capacity Rating [
]
T + M
Overall Capacity Rating =
Capacity Rating =
=
=
2
2
Completed by on
Comments:
Point
Point
Technical Capacity Assessment
Scale
Award
[T1] Does the water system have any significant deficiencies? [ Y N ]
N - 1pt.
Y - 0pt.
[T2] 1) Was the water treatment process functioning properly? [ Y N ] (i.e. Is ph, iron, free chlorine,
etc. within acceptable range?) 2) Was needed water system equipment in place and functioning
All Y - 1 pt.
properly at the time of survey? [ Y N ] (NOTE: Equipment deficiencies must be identified in survey
Else - 0 pt.
report.) 3) Were records available to the regional engineer clearly showing that all water storage tanks
have been inspected and cleaned or painted (if needed) within the past 5 years? [ Y N NA ]
[T3] 1) Was the certified waterworks operator or his/her authorized representative present for the
survey? [ Y N ] 2) Was PWS Operations Record up to date and properly maintained? [ Y N ] 3) Was
All Y - 1 pt.
water system properly maintained at time of survey? [ Y N ] 4) Did operator/system personnel
Else - 0 pt.
satisfactorily demonstrate to the regional engineer that he/she could fully perform all water quality tests
required to properly operate this water system? [ Y N ]
(NOTE: All YESs required to receive point)
[T4] 1) Does water system routinely track water production and were acceptable water production
records available for review by the regional engineer? [ Y N ] 2) Is water system overloaded? (i.e.
serving customers in excess of MSDH approved design capacity)? [ Y N ] 3) Was there any indication
1)Y - pt.
2)N - pt.
that the water system is/has been experiencing pressure problems in any part(s) of the distribution
3)N - pt.
system? [ Y N ] (based on operator information, customer complaints, MSDH records, other
4)Y - pt.
information) 4) Are well pumping tests performed routinely? [ Y N NA ]
(NOTE: YES for #1 & YES OR N/A/ FOR #4 and NOs for #2 & #3 required to receive point)
[T5] 1) Does the water system have the ability to provide water during power outages? (i.e. generator,
All Y - 1 pt.
emergency tie-ins, etc.) [ Y N ] NOTE: Systems may provide bottled water if included as part of a
Else - 0 pt.
published emergency plan. 2) Does the water system have a usable backup source of water? [ Y N ]
TECHNICAL CAPACITY RATING = [
] (Total Points)
Revision Date: 07/03/2019
Generated October 3, 2019, 10:55 AM CST.
NON-TRANSIENT, NON-COMMUNITY FORM
Mississippi Department of Health
Bureau of Public Water Supply
FY 2020 Public Water System Capacity Assessment Form
NOTE: This form must be completed whenever a routine sanitary survey of a public water system is conducted by a
regional engineer of the Bureau of Public Water Supply
PWS ID#:
Class:
Survey Date:
County:
Public Water System:
Conn:
Certified Waterworks Operator:
Pop:
CAPACITY RATING DETERMINATION
Technical (T) Capacity Rating: [
]
Managerial (M) Capacity Rating [
]
T + M
Overall Capacity Rating =
Capacity Rating =
=
=
2
2
Completed by on
Comments:
Point
Point
Technical Capacity Assessment
Scale
Award
[T1] Does the water system have any significant deficiencies? [ Y N ]
N - 1pt.
Y - 0pt.
[T2] 1) Was the water treatment process functioning properly? [ Y N ] (i.e. Is ph, iron, free chlorine,
etc. within acceptable range?) 2) Was needed water system equipment in place and functioning
All Y - 1 pt.
properly at the time of survey? [ Y N ] (NOTE: Equipment deficiencies must be identified in survey
Else - 0 pt.
report.) 3) Were records available to the regional engineer clearly showing that all water storage tanks
have been inspected and cleaned or painted (if needed) within the past 5 years? [ Y N NA ]
[T3] 1) Was the certified waterworks operator or his/her authorized representative present for the
survey? [ Y N ] 2) Was PWS Operations Record up to date and properly maintained? [ Y N ] 3) Was
All Y - 1 pt.
water system properly maintained at time of survey? [ Y N ] 4) Did operator/system personnel
Else - 0 pt.
satisfactorily demonstrate to the regional engineer that he/she could fully perform all water quality tests
required to properly operate this water system? [ Y N ]
(NOTE: All YESs required to receive point)
[T4] 1) Does water system routinely track water production and were acceptable water production
records available for review by the regional engineer? [ Y N ] 2) Is water system overloaded? (i.e.
serving customers in excess of MSDH approved design capacity)? [ Y N ] 3) Was there any indication
1)Y - pt.
2)N - pt.
that the water system is/has been experiencing pressure problems in any part(s) of the distribution
3)N - pt.
system? [ Y N ] (based on operator information, customer complaints, MSDH records, other
4)Y - pt.
information) 4) Are well pumping tests performed routinely? [ Y N NA ]
(NOTE: YES for #1 & YES OR N/A/ FOR #4 and NOs for #2 & #3 required to receive point)
[T5] 1) Does the water system have the ability to provide water during power outages? (i.e. generator,
All Y - 1 pt.
emergency tie-ins, etc.) [ Y N ] NOTE: Systems may provide bottled water if included as part of a
Else - 0 pt.
published emergency plan. 2) Does the water system have a usable backup source of water? [ Y N ]
TECHNICAL CAPACITY RATING = [
] (Total Points)
Revision Date: 07/03/2019
Public Water System:
PWS ID #:
FY 2020 Public Water System Capacity Assessment Form
Survey Date:
Point
Point
Management Capacity Assessment
Scale
Award
[M1] Were all SDWA required records maintained in a logical and orderly manner and available for
Y - 1pt.
review by the regional engineer during the survey? [ Y N ]
N - 0pt.
[M2] Have acceptable written policies and procedures for operating this water system been formally
Y - 1pt.
adopted and were these policies and procedures available for review during the survey? [ Y N ]
N - 0pt.
[M3] Has the water system had any SDWA violations since the last Capacity Assessment? [ Y N ]
N - 1pt.
Y - 0pt.
[M4] Has the water system developed a preventive maintenance schedule and was a copy of this
Y - 1pt.
schedule available for review during survey? [ Y N ]
N - 0pt.
[M5] 1) Does the water system have an effective cross connection control program in compliance with
MSDH regulations? [ Y N ] 2) Was a copy of the MSDH approved bacti sample site plan and lead and
All Y - 1 pt.
copper sample site plan available for review and do bacti results clearly show this approved plan is
Else - 0 pt.
being used for all bacti monitoring? [ Y N ]
MANAGEMENT CAPACITY RATING = [
] (Total Points)
Revision Date: 07/03/2019
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