Washington State Department of Health Office of Drinking Water Headquarters Town Center 3 243 Israel Road SE, Tumwater P.O. Box 47822 Olympia, WA 98504-7822 360-236-3100 or 800-521-0323 Eastern Regional Office 16201 E Indiana Ave, Suite 1500 Spokane Valley, WA 99216 509-329-2100 (Adams, Asotin, Benton, Chelan, Columbia, Douglas, Ferry, Franklin, Garfield, Grant, Kittitas, Klickitat, Lincoln, Okanogan, Pend Oreille, Spokane, Stevens, Walla Walla, Whitman and Yakima) Northwest Regional Office 20425 72nd Ave. S., Suite 310 Kent, WA 98032 206-395-6750 (Island, King, Pierce, San Juan, Skagit, Snohomish and Whatcom) Southwest Regional Office Town Center 3 243 Israel Road SE, Tumwater P.O. Box 47823 Olympia, WA 98504-7823 360-236-3030 (Clallam, Cowlitz, Clark, Grays Harbor, Jefferson, Kitsap, Lewis, Mason, Pacific, Skamania, Thurston and Wahkiakum) Small Water System Management Program (Water System Name) (Water System Owner Name)
Section 3 – Emergency Reference List List important parties to contact. Emergency contact Phone Number(s) Emergency contact Phone number(s) County emergency services Certified operator(s) Local health jurisdiction System engineer or engineering consultant Department of Ecology spill response Electrician Water testing lab Electric utility DOH water quality contact Pump service Neighboring water system Equipment rental DOH emergency after hours contact 1-877-481-4901 Other Section 4 – Response Actions for Specific Events Identify action to take in the following events. Immediate actions to take (assess damage, contact DOH, contact repair service) Who should be notified (DOH, customers, repair service, county) Power outage Line break Chlorine treatment failure Source pump failure Coliform MCL Severe reduction or loss of source Other:
Table 3-5 Water Rights Self-Assessment Existing Status Permit certificate or claim number Name on document Priority Date (List oldest first) Source Name and Number Any portion supplemental? (If yes, explain in footnote) Existing Water rights Existing consumption Current water right status (Excess/Deficiency) Maximum Instantaneous Flow Rate (Qi) Maximum Annual Volume (Qa) Maximum Instantaneous Flow Rate (Qi) Maximum Annual Volume (Qa) Maximum Instantaneous Flow Rate (Qi) Maximum Annual Volume (Qa) Permits/ Certificates 1. 2. 3. 4. Claims 1. 2. 3. 4. TOTAL Intertie name or Identifier Name of purveyor Providing water Existing limits on intertie use Existing consumption through intertie Current intertie supply status (Excess/Deficiency) Maximum Instantaneous Flow Rate (Qi) Maximum Annual Volume (Qa) Maximum Instantaneous Flow Rate (Qi) Maximum Annual Volume (Qa) Maximum Instantaneous Flow Rate (Qi) Maximum Annual Volume (Qa) 1. 2. 3. 4. TOTAL Pending water right application (New/Change) Name on application Date submitted Any portion supplemental? (If yes, explain in footnote) Pending water rights Maximum Instantaneous Flow Rate (Qi) Requested Maximum Annual Volume (Qa) Requested 1. 2. 3. 4.
Table 4-1 A Short-Lived Component Inventory (service life is 6 years or less) Short-Lived Asset Component Size, Length, Diameter, and/or Capacity Where necessary, list each component separately Year Constructed or Installed Estimated Life Expectancy Current Age Estimated Cost to Replace Replace in Next 6 Years? Hypo-Chlorination System 3-5 Years No Yes If Yes, Year UV Light 1 Year No Yes If Yes, Year Software (SCADA, cross-connection control) 5-9 Years No Yes If Yes, Year Filters and Filter Media 5-9 Years No Yes If Yes, Year Pressure Tanks (bladder) 6-9 Years No Yes If Yes, Year Building Heat and Cooling 5-9 Years No Yes If Yes, Year Instrument Switches and Gauges 5-9 years No Yes If Yes, Year Other years No Yes If Yes, Year
Table 4-1B Long-Lived Component Inventory (service life is 7 years or longer) Long-Lived Component Size, Length, Diameter, and/or Capacity Where necessary, list each component separately Year Constructed or Installed Estimated Life Expectancy Current Age Estimated Cost to Replace Replace in Next 6 Years? EXAMPLE Well Well 1 8-inch diameter and 200 feet deep Drilled 1924 50-100 years 87 years No Yes (Well #1) If Yes, Year 2014 Well 2 12-inch diameter and 145 feet deep Drilled 1986 25 years EXAMPLE Submersible Well Pump Well 1 10 hp Installed 1996 10-15 years 15 years No Yes If Yes, Year ____ Well 2 25 hp Installed 2006 5 years Well 50-100 years No Yes If Yes, Year Submersible Well Pump 10-15 years No Yes If Yes, Year Turbine Well Pump 25-50 years No Yes If Yes, Year Source Meter 15-30 years No Yes If Yes, Year Well and Pump House 25-100 years No Yes If Yes, Year Reservoirs 50-100 years No Yes If Yes, Year
Long-Lived Component Size, Length, Diameter, and/or Capacity List each individual component separately Year Constructed or Installed Estimated Life Expectancy Current Age Estimated Cost to Replace Replace in Next 6 Years? Pressure Tanks (hydropneumatic) 50 years No Yes If Yes, Year Booster Pumps 10-20 years No Yes If Yes, Year Back-up Power Generator 15-30 years No Yes If Yes, Year Electrical Service/Breaker 20 years No Yes If Yes, Year Motor Starter/Control Relays 10-20 years No Yes If Yes, Year Other years No Yes If Yes, Year