(for Fluming and Cleaning) Assessment Instructions: Complete and/or update annually for all water sources. Check off () those items that apply. Make additional copies as necessary and complete Page __ of __ to indicate more than one page if required. Completed by: Date: Page _____ of ______ Water tests Water Dates When Corrective source Cleaning and Items to Assess Stored will the Use Method Actions (*see (e.g., ()? *** (check each item) Treatment** water to 2nd ()? examples below) municipal, first be use test well, surface) used? test Fluming Pit Animal access Cleaned Washing Spray Runoff Treated Final rinse Hose Working condition Cistern Hand Tap of well/pipes Well washing Dump tank Other possible Other: Cleaning Pressure wash hazards assessed Using Appendix: equipment/ Other: _______ (describe): A B H containers/ ___________ OR: building ____________ Fluming Pit Animal access Cleaned Washing Runoff Treated rinse Hose Working condition Cistern Hand Tap of well/pipes Well washing Dump tank Other possible Other: Cleaning Pressure wash hazards assessed Using Appendix: equipment/ Other: _______ (describe): A B H containers/ ___________ OR: building ____________ Fluming Pit Animal access Cleaned Washing Spray Runoff Treated Final rinse Hose Working condition Cistern Hand Tap of well/pipes Well washing Dump tank possible Other: Cleaning Pressure wash hazards assessed Using Appendix: equipment/ Other: _______ (describe): A B H containers/ ___________ OR: building ____________ Assessment Assessment should include runoff from agricultural chemicals, fuels or manure; contamination in pipes, cleanliness of cistern etc. *Corrective -Install -Test Actions: devices to water for prevent Total backflow Coliforms and E. coli using an accredited lab conforming
(for Fluming and Cleaning) Assessment Instructions: Complete and/or update annually for all water sources. Check off () those items that apply. Make additional copies as necessary and complete Page __ of __ to indicate more than one page if required. Completed by: Date: Page _____ of ______ Water source (e.g., municipal, well, surface) ()? Stored ()? *** Use Method Items to Assess (check each item) Water tests Corrective Actions (*see examples below) Cleaning and Treatment** When will the water first be used? Dates to use test 2nd test Fluming Washing Final rinse Hand washing Cleaning equipment/ containers/ building Pit Spray Hose Tap Dump tank Pressure wash Other: _______ ___________ Animal access Runoff Working condition of well/pipes Other possible hazards assessed (describe): Cleaned Treated Cistern Well Other: Using Appendix: A B H OR: ____________ Fluming Washing rinse Hand washing Cleaning equipment/ containers/ building Pit Hose Tap Dump tank Pressure wash Other: _______ ___________ Animal access Runoff Working condition of well/pipes Other possible hazards assessed (describe): Cleaned Treated Cistern Well Other: Using Appendix: A B H OR: ____________ Fluming Washing Final rinse Hand washing Cleaning equipment/ containers/ building Pit Spray Hose Tap Dump tank Pressure wash Other: _______ ___________ Animal access Runoff Working condition of well/pipes possible hazards assessed (describe): Cleaned Treated Cistern Well Other: Using Appendix: A B H OR: ____________ Assessment Assessment should include runoff from agricultural chemicals, fuels or manure; contamination in pipes, cleanliness of cistern etc. *Corrective Actions: -Install devices to prevent backflow -Test water for Total Coliforms and E. coli using an accredited lab conforming