Questionnaire for

Drinking Water Utilities Participating in Emerging Contaminant Sampling
Program 

EPA ICR No. 2346.01, OMB Control No. 2080-NEW  

Thank you for agreeing to participate in the Emerging Contaminant
Sampling Program.  The information gathered on the following
questionnaire will be used by the US Environmental Protection Agency’s
Office of Research and Development to better interpret the results of
the sampling project.  Please complete and return the questionnaire as
soon as possible after sampling.  Electronic submissions are preferred,
but paper submissions will be accepted.  Submissions and questions
should be directed to:

				Susan T. Glassmeyer, Ph.D

				US Environmental Protection Agency

				26 W. Martin Luther King Dr

				MS 564

				Cincinnati, OH 45268

				glassmeyer.susan@epa.gov

				(p) 513-569-7526

Part A. Contact Information

Facility Name

	Water System ID

Date

	Address

	City

State

Zip

	Contact person

Title

	E-mail

Phone

	Website

					(f)  513-569-7757

Part B. Location Information

City/region served

	Population served

	What source water(s) does the facility draw from? Provide both name of
waterbody and nature of source water (river, lake reservoir, shallow
well, deep well). If multiple water sources are used, provide percentage
of total flow from each source.



	For surface waters, is the source water currently low, average or high
(in terms of flow and/or stage)?  If actual measurements are available,
please provide such measurements of discharge and/or stage of the source
water at time of sampling.



	Have the source and/or finished water ever been analyzed for emerging
contaminants?  If so, please supply analyte(s), measured
concentration(s), analyst(s), and date of analysis.



	How many and what type of wastewater outfalls are located within 25
miles upstream of the plant’s intake pipes?  Can you provide a source
for this information if you do not have it yourself?



	How many and what type of industrial outfalls are located within 25
miles upstream of the plant’s intake pipes?  Can you provide a source
for this information if you do not have it yourself?



	Is the source water impacted by agrichemicals (such as pesticides,
fertilizers)?



	After water leaves the clear well, is it blended with waters from other
sources in your system? If so, describe the other source and typical
blending composition or range of composition.



	Is water from this plant’s distribution system sold to another
utility’s system?  If so, which system, and how much is provided?



	

Part C. Treatment Information

Plant age

	Minimum, mean, and maximum daily pumpage (mgd)

	Pumpage at sampling (mgd)

	Ratio of domestic to industrial useage

	Overall residence time from source water to finished water collection
points (hours)

	What treatment processes are employed in the plant?  Include those
processes that are intermittent or brought on line as needed.  Please
list them in order from raw to finished water.  If treatment is split,
indicate the processes on the parallel treatment trains.  If multiple
sources are used, please indicate the point at which each source is
introduced into the treatment train.  Include treatment that is
simultaneous or concurrent; for example, PAC with
coagulation/clarification, chlorine with filtration, etc.



	In addition to the source (untreated) water and the clear well effluent
(finished) water, after which processes can samples be collected?



	For treatments that are intermittent or as needed, for what purpose are
they brought online?  For example, powdered activated carbon (PAC) for
taste and odor control, chlorine for manganese control, copper sulfate
for algal control, etc.



	Is there a disinfectant residual present in the filter?



	If PAC is used, what is its purpose? For example, taste and odor
control.  What brand and size of PAC is used? What is the estimated
contact time?



	For each PAC purpose, what dose is applied? 



	If GAC is used, what is its purpose? For example, taste and odor
control, DBP precursor control.  What brand of GAC is used?



	How often is GAC replaced or reactivated?



	On what basis is GAC replaced/reactivated?  For example, chlorine
breakthrough, TOC breakthrough, taste-and-odor breakthrough.



	Describe how the GAC is used.  For example, as a 12-inch cap over sand,
in a post-filter contactor of 6-foot depth.  At current flow, what is
the empty bed contact time?



	Is a disinfectant residual applied to the GAC?



	If membranes are used, describe their type (MF, UF, NF, RO) and
purpose.  What brand of membrane is used?



	For each disinfectant/oxidant, what is the dose at each application
point? Include free chlorine, combined chlorine, chlorine dioxide,
transferred ozone, and permanganate.



	If chloramines are used, describe how they result.  For example,
preformed chloramine, chlorination of influent ammonia, free chlorine
contact time followed by ammonia addition.



	If the plant uses UV, describe its purpose.  Give the dose in mJ/cm2.



	If the plant uses advanced oxidation (ozone/H2O2, UV/H2O2, etc),
describe its purpose.  Give the dose of each (transferred ozone in mg/L,
H2O2 in mg/L, UV in mJ/cm2).



	What disinfectant residuals are in the clear well effluent (finished
water)?  For example, 2.4 mg/L free chlorine and 0.4 mg/L combined
chlorine, 1.6 mg/L free chlorine and 0.5 mg/L chlorine dioxide, 2.6 mg/L
free chlorine only, 2.2 mg/L combined chlorine only.



	Which processes are used to achieve CT credit by disinfection?



	Which processes are used to achieve CT credit by physical removal?



	

Part D. USEPA Sample Collection Form

Please fill out on sampling day(s), one form for Source Water, one for
Finished Water.



	Station ID

	Sample Location

	Collection Date (YYYYMMDD)

	Collection Start Time (HHMM)

	Collection End Time (HHMM)



	Water Quality Parameters

Temperature

	pH

	Specific Conductance

	Turbidity

	Other Parameters















	USEPA Sample Log in

Date

	Time

	Condition







EPA ICR No. 2346.01, OMB Control No. 2080-NEW  						Page   PAGE  5  of 
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