EPA Form 6100-02

OMB No.: 

Approval Expires: 

 U. S . E nvironment al P rot ec t ion A genc y Federal PWSID No.:

Please verify or correct the following information:

Name of System (Community): 

Name of Contact: 

Street Address: 

City, State, and Zip: 

Population Served (if wholesaler, 

include consecutive population 

as appropriate): 

Number of Connections (not 

including consecutive systems): 

Total System Design Capacity (in 

MGD): 

Total Length of Pipe in System 

(in Feet): 

Ground Surface/GWUDI

Purchased Ground Purchased Surface/GWUDI

Public Investor-Owned or 

Federal Government Private Non-Profit

State Reviewer: Telephone Number:

Washington, DC 20460

Check if Correct Corrected Information

as Printed

Source Water Type (Ground, Surface/GWUDI, etc.): 

Ownership Type: 

Check All That Apply:

Information provided for this survey can be requested by the public. It is our experience that this information is rarely requested.

Public reporting burden for this collection of information is estimated to average 5.53 hours per response. This estimate includes time for review ing the instructions, searching existing data sources, 

gathering and maintaining the data needed, and completing and review ing the information collected. Burden means the total time, effort, or financial resources expended by person(s) to generate, 

maintain, retain, or disclose or provide information to or for a Federal Agency. This includes the time needed to review instructions; develop, acquire, install, and utilize technology and systems for 

the purposes of collecting, validating, and verifying information; adjust the existing w ays to comply w ith any previously applicable instructions; search data sources; complete and review the 

collection of information; and transmit or otherw ise disclose the information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it 

displays a currently valid OMB control number. The OMB control numbers for EPA’s regulations are listed in 40 CFR Part 9 and 48 CFR Chapter 15.

Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use 

of automated collection techniques to the Director, OPPI, Regulatory Information Division, U.S. Environmental Protection Agency (1804A), Ariel Rios Building, 1200 Pennsylvania Ave., NW, 

Washington, DC 20460; and Office of Information and Regulatory Affairs, Office of Management and Budget, 725 17th Street, N.W., Washington, DC 20503.

State Use Only

Check All That Apply:

Needs Survey And Assessment

2015 Drinking Water Infrastructure

(Fill in only if preprinted information is missing or incorrect)
EPA Form 6100-02

Project Table Federal PWSID No.: 

Project 

Number Project Name Type of Need 

Reason 

for Need N,E,R,H C or F

RegulationDesign 

Capacity Diameter Length Number Needed 

Cost 

Estimate 

Cost 

Date 

Documentation 

Remove 

M odify or 

Validate

Comment 

Codes

0
EPA Form 6100-02

To ensure all potential source, treatment, and storage projects are considered, it may be helpful to complete some or all of this inventory table. 

How ever, completion of this table is not required.

 ▪ Source Projects are all projects related to collecting and pumping raw w ater. This includes w ells, surface w ater intakes, springs, off-stream raw 

 w ater storage, and pumps.

 ▪ Treatment Projects are all projects related to disinfection, filtration, or other treatment processes for ground or surface w ater sources, or for 

 treatment applied in the distribution system.

 ▪ Storage and Pumping Projects are related to finished or treated w ater storage, and booster pump stations.

Existing Raw Surface Water Pumps:

Source, Treatment, Storage, and Pumping Inventory

Source Water

Inventory Needing Replacement Needing Rehabilitation New Infrastructure Needs

For the sources identified above, enter the number of locations w here the follow ing treatment is applied: Does your system have additional treatment needs for 

provisions of additional public health protection or for 

aesthetic concerns?

Disinfection (including booster 

disinfection):

Disinfection:

Total Number and Capacity of Existing 

Wells or Springs: 

Wells (pumps included) or Springs: Wells (pumps included) or Springs: Does your system have additional source w ater capacity 

needs to meet the needs of current users?

Total Number and Capacity of Existing 

Surface Water Sources: 

Existing Surface Water Intakes 

(excluding pumps): 

Existing Surface Water Intakes (excluding 

pumps): If yes, how many additional sources are necessary?

Total Number and Capacity of Existing 

Pumps (excluding booster pump 

stations):

Existing Groundw ater Pumps (if w ells 

not listed):

Existing Groundw ater Pumps (if w ells not 

listed): 

Existing Raw Surface Water Pumps:

Filtration: Filtration:

Chemical removal or addition: Chemical treatment: Chemical treatment:

Treatment

Inventory Needing Replacement

Needing Expansion/Upgrading or 

Rehabilitation New Infrastructure Needs

Disinfection:

Total Number and Capacity of Existing 

Booster Pump Stations:

Number of Existing Booster Pump 

Stations: 

Number of Existing Booster Pump 

Stations: If yes, how much additional finished w ater storage or 

booster pumping capacity is necessary?

Storage and Pump Stations

Total Number and Capacity of Existing 

Storage Tanks: 

Number of Existing Elevated or GroundLevel Storage Tanks: Number of Existing Elevated or GroundLevel Storage Tanks:Does your system have additional storage capacity and/or 

booster pumping needs to meet the needs of current 

users?

Inventory Needing Replacement Needing Rehabilitation New Infrastructure Needs

If yes, how much additional treatment is necessary?

Filtration:

Yes No

Yes No

Yes No
EPA Form 6100-02

Transmission and Distribution Inventory

On the table below , please provide an estimate of the total feet or miles of pipe in your system, if possible. Completion of this table is not required, but it may be helpful to

ensure all potential transmission and distribution pipe projects are considered.

 feet Total Pipe

 miles in System

(Check feet or miles)

Total Pipe in System

(Check feet or miles) <=6 inch 8-12 inch 15-42 inch >=48 inch

 feet 

 miles Amount of PVC by pipe size

 feet 

 miles

 feet 

 miles

 feet 

 miles

 feet 

 miles

% of total 

pipe

% of this category/size pipe 

currently in poor condition or 

beyond useful life % % % %

 feet 

 miles

Amount of ductile iron by pipe 

size

 feet 

 miles

 feet 

 miles

 feet 

 miles

 feet 

 miles

% of total 

pipe

% of this category/size pipe 

currently in poor condition or 

beyond useful life % % % %

 feet 

 miles Amount of cast iron by pipe size

 feet 

 miles

 feet 

 miles

 feet 

 miles

 feet 

 miles

% of total 

pipe

% of this category/size pipe 

currently in poor condition or 

beyond useful life % % % %

 feet 

 miles

Amount of asbestos cement by 

pipe size

 feet 

 miles

 feet 

 miles

 feet 

 miles

 feet 

 miles

% of total 

pipe

% of this category/size pipe 

currently in poor condition or 

beyond useful life % % % %

 feet 

 miles Amount of other by pipe size

 feet 

 miles

 feet 

 miles

 feet 

 miles

 feet 

 miles

% of total 

pipe

% of other currently in poor 

condition or beyond useful life % % % %

Cast Iron

Asbestos

Cement

Other

Transmission and distribution projects are the piping needs of a w ater system. Projects for valves, backflow prevention devices and assemblies, and meters that 

are not part of a transmission or distribution project listed in this table should be recorded in the table under the tab titled "Inventory Table 3".

Note: The total feet or miles or pipe in your system is required information if any pipe projects are 

submitted based solely on survey-generated documentation (documentation codes 10 or 11).

Plastic

Ductile

Iron
EPA Form 6100-02

Meters, Service Lines, Backflow Prevention Devices/Assemblies, Valves, etc.

Projects for meters, service lines, backflow prevention devices and assemblies, valves, and other miscellaneous projects

are recorded in this section to accommodate entries of multiple identical items on one line in the project table. 

Record only projects that are not a part of another project (e.g., water main replacement projects will already include valves and other appurtenances). 

To ensure all potential projects are considered, it may be helpful to complete some or all of this inventory table. However, completion of this table is not required.

Total Number of Existing Water 

Meters:

Number of Water Meters: Number of Water Meters:

Total Number of Existing Backflow 

Prevention Devices/Assemblies:

Number of Backflow Prevention 

Devices/Assemblies:

Number of Backflow Prevention 

Devices/Assemblies:

Total Number of Valves: Number of Valves: Number of Valves:

Total Number of Lead Service Lines:

EPA requires documentation of all projects provided. Applicable types of documentation are presented in List 4 of the Lists of Codes. 

Use only existing documentation of cost. We do not expect you to develop new cost estimates.

Inventory Needing Replacement New Infrastructure Needs
EPA Form 6100-02

Respondent Information

Telephone Number:

Fax Number:

E-mail Address:

Best Time to Reach You:

If you have any questions, contact your state coordinator.

CLOSING: Thank you for your help. Did you remember to?

Identify, by project number, available documentation for all needs and costs reported?

Email the questionnaire and email or mail the documentation to your state?

Please provide the following information in case we need to contact you for clarification or additional explanation of any of your responses.

Contact Person (Person who completed this questionnaire):

Signature:

Name (please print): 

Title:

Mailing Address:

(Street Address)
EPA Form 6100-02

Summary of Survey-Generated and Independent Documentation for Each Project Federal PWSID No.: 0

Project 

Number Project Name 

Documentation 

Code(s)

State/System Survey-Generated Statement Independent 

Document Name

Independent 

Documentation 

Page Number(s)