Hawaii Department of Health Safe Drinking Water Branch RTCR-Level 2 – Coliform Bacteria Level 2 Assessment Form System Name: Source Water: PWSID # Operator in Responsible Charge (ORC) : Phone: Sample Collector(s) (if different from ORC): Date Assessment Triggered: Date of Site Persons Present: Date Assessment completed: Assigned (Yes, No, Questions Comments / Issues found To N/A) Action Y 1. Evaluate sample site. a. Is there a dedicated sample tap? Screwed-on cap? b. Height of tap above ground? c. Leaky or swivel faucet used? Have there been any plumbing changes or construction? If d. yes, when and what was the repair or change? Have there been any plumbing breaks or failure? If yes, e. when? List any identified after the service f. connection or in premise plumbing. Were all backflow prevention devices present, operational, g. tested annually by a certified tester and maintained? Were there any low pressure events after the service h. connection or in premise plumbing? If yes, when? i. Other comments on sample site? 2. Sampling protocol followed? Aerator, screen, hose or other attachment present during a. sampling? b. Tap flushed for less than 3 minutes? c. Tap not disinfected or cleaned?
Hawaii Department of Health – Safe Drinking Water Branch RTCR-Level 2 Coliform Bacteria Level 2 Assessment Form System Name: Source Water: PWSID # Operator in Responsible Charge (ORC) : Phone: Sample Collector(s) (if different from ORC): Date Assessment Triggered: Date of Site Persons Present: Date Assessment completed: Questions Assigned To (Yes, No, N/A) Comments / Issues found Y 1. Evaluate sample site. a. Is there a dedicated sample tap? Screwed-on cap? b. Height of tap above ground? c. Leaky or swivel faucet used? d. Have there been any plumbing changes or construction? If yes, when and what was the repair or change? e. Have there been any plumbing breaks or failure? If yes, when? f. List any identified after the service connection or in premise plumbing. g. Were all backflow prevention devices present, operational, tested annually by a certified tester and maintained? h. Were there any low pressure events after the service connection or in premise plumbing? If yes, when? i. Other comments on sample site? 2. Sampling protocol followed? a. Aerator, screen, hose or other attachment present during sampling? b. Tap flushed for less than 3 minutes? c. Tap not disinfected or cleaned? Action