2017 EPA Region 8 TRIBAL SANITARY SURVEY FORM INVENTORY DATE OF SURVEY: RESERVATION: SURVEYOR NAME(S): PWS ID: SYSTEM NAME: System representatives (including titles) present at survey: EMERGENCY CONTACT Emergency Contact Name: IHS team members present: Emergency cell phone: ( ) BOR team members present: Emergency email address: Tribal engineer present: Title: Comments: Street: City: State: County: Zip: SYSTEM OR LEGAL REPRESENTATIVE PRIMARY ADMINISTRATIVE CONTACT (to receive ALL correspondence from EPA) Addressee Name: Addressee: Title: Company (if Corporation, name of Corporation): Street: Street: City: State: Zip: City: State: Zip: Administrative Contact ( ) Fax: ( ) Owner Phone: ( ) Fax: ( ) Email Address: Email Address: Tribal Chairman (if different than ADDITIONAL CONTACT PUBLIC WORKS DIRECTOR, (if any) TRIBAL ENGINEER and/or WATER PLANT SUPERINTENDENT Addressee: Addressee: Title: Title: Street: Street: City: State: County: Zip: City: County: Zip: Contact Phone: ( ) Fax: ( ) Contact Phone: ( ) Fax: ( ) Email Address: Email Address: Comments: DESIGNATED OPERATOR OF SYSTEM ALTERNATE OPERATOR Name: Name: Certified Operator? Yes No Not required Certified Operator? @ Yes No TNC System (not required) Treatment Cert. Level: Distribution Cert. Level: Treatment Cert. Level: Distribution Cert. Level: Treatment Cert. Exp. Date: Distribution Cert. Exp. Date: Treatment Cert. Exp. Date: Distribution Cert. Exp. Date: Cert. Authority: Cert. Authority: Cert. Authority: Cert. Authority: Phone: ( ) Phone: ( ) Email Address: Email Address: Comments: Contract Operator*? Yes No Date contract ends: Comments: WATER SYSTEM CLASSIFICATION BY EPA WATER SYSTEM CLASSIFICATION for operator certification from PWS Inventory System Treatment Classification C = Community System Distribution Classification NTNC = Non-Transient Non-Community Comments: NC = Transient NonCommunity Comments: SYSTEM PHYSICAL ADDRESS PHYSICAL LOCATION Street: Physical Location and Directions: City: State: Zip:
2017 EPA Region 8 TRIBAL SANITARY SURVEY FORM INVENTORY DATE OF SURVEY: RESERVATION: SURVEYOR NAME(S): PWS ID: SYSTEM NAME: System representatives (including titles) present at survey: IHS team members present: BOR team members present: Tribal engineer present: Comments: EMERGENCY CONTACT Emergency Contact Name: Emergency cell phone: ( ) Emergency email address: Title: Street: City: State: County: Zip: SYSTEM OR LEGAL REPRESENTATIVE Addressee Name: Company (if Corporation, name of Corporation): Street: City: State: Zip: Owner Phone: ( ) Fax: ( ) Email Address: Tribal Chairman (if different than PRIMARY ADMINISTRATIVE CONTACT (to receive ALL correspondence from EPA) Addressee: Title: Street: City: State: Zip: Administrative Contact ( ) Fax: ( ) Email Address: ADDITIONAL CONTACT (if any) Addressee: Title: Street: City: State: County: Zip: Contact Phone: ( ) Fax: ( ) Email Address: Comments: PUBLIC WORKS DIRECTOR, TRIBAL ENGINEER and/or WATER PLANT SUPERINTENDENT Addressee: Title: Street: City: County: Zip: Contact Phone: ( ) Fax: ( ) Email Address: DESIGNATED OPERATOR OF SYSTEM Name: Certified Operator? @ Yes No TNC System (not required) Treatment Cert. Level: Distribution Cert. Level: Treatment Cert. Exp. Date: Distribution Cert. Exp. Date: Cert. Authority: Cert. Authority: Phone: ( ) Email Address: Contract Operator*? Yes No Date contract ends: Comments: ALTERNATE OPERATOR Name: Certified Operator? Yes No Not required Treatment Cert. Level: Distribution Cert. Level: Treatment Cert. Exp. Date: Distribution Cert. Exp. Date: Cert. Authority: Cert. Authority: Phone: ( ) Email Address: Comments: WATER SYSTEM CLASSIFICATION BY EPA for operator certification System Treatment Classification System Distribution Classification Comments: WATER SYSTEM CLASSIFICATION from PWS Inventory C = Community NTNC = Non-Transient Non-Community NC = Transient NonCommunity Comments: SYSTEM PHYSICAL ADDRESS Street: City: State: Zip: PHYSICAL LOCATION Physical Location and Directions: