
DRAFT
CWSS
2006
Questionnaire
DRAFT
2006
Community
Water
System
Survey
Draft
Questionnaire
Version
6
May
12,
2006
DRAFT
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
1
Please
provide
the
name,
title,
and
telephone
number
of
the
most
knowledgeable
person
to
contact
for
information.
Also,
please
provide
the
name
of
the
responder
if
it
does
not
match
the
label:

A.
Part
I
 
Operating
Characteristics
B.
Part
II
 
Financial
Characteristics
(
Write
"
SAME"
if
same
as
A)

Name:

Title:

Tel.
No.

Fax
No.

e­
mail:

2
This
survey
will
ask
you
to
provide
operating
and
financial
information
for
your
public
water
system
for
the
most
recent
12­
month
period
for
which
data
are
available.
Please
specify
below
the
end
dates
for
which
data
are
provided.

A
Operating
information
(
end
date)
mm
dd
yy
B
Financial
information
(
end
date)
mm
dd
yy
DRAFT
1
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
3
Please
classify
your
water
system
using
the
following
criteria.
(
Please
check
one
only)

4
A
Do
you
have
regular
access
to
a
computer
for
sending
and
receiving
information?

Yes
No
(
Skip
to
question
5)

B
Do
any
of
your
computers
have
the
following
features?
(
Please
check
all
that
apply)

1
Microsoft
Excel
2
Microsoft
Access
3
CD
drive
4
DVD
player
C
What
access
do
you
have
to
the
internet
(
please
check
one
)?

1
High
speed
internet
access
(
e.
g.,
cable,
DSL,
wireless,
or
T1)

2
Dial­
up
modem
access
3
No
access
Owned
and
operated
by
a
government
or
public
agency
(
not
including
government­
owned
systems
that
hire
a
private
company
to
operate
the
system)

Owned
privately
and
operated
for
profit
primarily
as
a
water
business
(
e.
g.,
American
Water
Company)

Owned
privately
and
not
operated
for
profit
(
e.
g.,
a
homeowners
association
or
a
non­
profit
cooperative)

Owned
privately
and
operated
as
a
necessary
part
of
another
business
(
e.
g.,
a
mobile
home
park)

Owned
by
a
government
or
public
agency
and
operated
by
a
private
contractor
DRAFT
2
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
Term
Example
Code
Definition
Figure
1:
Sample
Diagram
of
Intakes,
Treatment
Plants,
and
Entry
Points
Surface
water
intake
S1,
S2
A
surface
water
intake
refers
to
the
structure
at
the
surface
water
source
(
flowing
stream,
lake,
reservoir,
or
ground
water
under
the
direct
influence
of
surface
water)
that
permits
the
withdrawal
of
the
water
from
that
source.
(
See
accompanying
diagram).

Ground
water
source
G1,
G2,

G3,
G4
A
ground
water
source
refers
to
the
connection
of
untreated
water
from
one
or
more
wells
to
a
water
treatment
plant
or
directly
into
the
distribution
system.
Where
the
water
from
multiple
wells
flows
through
a
common
pipe
prior
to
entry
into
the
treatment
plant
or
distribution
system,
the
combined
flow
is
considered
one
ground
water
source.
(
See
accompanying
diagram.)

Purchased
water
connection
P1,
P2
A
purchased
water
connection
refers
to
the
transmission
of
water
from
the
seller's
water
system
to
a
water
treatment
plant
or
directly
into
the
distribution
system
of
the
purchaser's
water
system.
(
See
accompanying
diagram.)

Water
treatment
plant
WTP
1,

WTP
2
Buyer
B1,
B2
A
water
treatment
plant
is
any
facility
where
water
is
filtered,
disinfected,
and/
or
otherwise
treated
prior
to
its
transmission
into
the
distribution
system
(
or
its
conveyance
to
another
purchasing
water
system).
For
the
purposes
of
this
survey,
simple
disinfection
only
or
pH
adjustment
prior
to
entry
into
the
distribution
system
are
considered
to
be
a
water
treatment
plant.
Other
examples
include
large
scale
filtration
plants
and
chemical
feed
on
wells
for
disinfection.
It
does
not
include
facilities
within
the
distribution
system
that
boost
disinfection.

A
buyer
refers
to
any
system/
source
where
ownership
is
transferred
to
another
party
for
a
monetary
value.

The
following
definitions
of
the
components
of
a
water
system
are
used
in
this
survey.
Figure
1
is
an
example
of
a
schematic
of
a
water
system
showing
water
sources,

treatment
plants,
transmission
lines,
and
the
distribution
system.

Please
refer
to
these
definitions
and
the
schematic
for
an
explanation
of
the
terms
used
in
questions
6
through
11.
Please
submit
diagrams
or
schematics,
using
figure
1
as
a
guide.

Please
note
that
the
identifier
numbers
used
in
the
questions
do
not
refer
to
specific
items
in
figure
1.
For
example,
use
`
S1'
to
refer
to
your
first
surface
water
source,

regardless
of
whether
it
is
a
flowing
stream,
as
depicted
in
the
schematic,
or
another
surface
water
source.

DRAFT
3
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
Entry
point
E1,
E2,
E3,

E4
An
entry
point
is
where
treated
or
untreated
potable
water
enters
into
the
water
system's
distribution
system.

DRAFT
4
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
5
Please
draw
your
schematic
here
or
submit
a
schematic
on
a
separate
sheet
of
paper.
Figure
1
is
an
example
of
the
type
of
schematic
required.

DRAFT
5
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
6
Provide
the
following
information
for
the
ground
water
sources,
surface
water
intakes,
and
purchased
water
connections
for
this
water
system.

MG
is
millions
of
gallons
of
water.

MGD
is
millions
of
gallons
per
day.

If
the
source
is
used
on
a
seasonal
or
emergency
basis,
the
average
daily
amount
is
for
the
days
the
source
is
used.

A
Ground
water
sources
grouped
by
entry
point
to
the
distribution
system.

Ground
water
sources
grouped
by
entry
point
to
the
distribution
system
How
many
individual
wells
supply
each
ground
water
entry
point?
Is
this
a
seasonal
source?

(
Yes
or
No)
Is
this
an
emergency
source?

(
Yes
or
No)
If
this
is
a
seasonal
or
emergency
source,
how
many
months
was
it
used
in
the
12
month
period
reported
in
question
2A?
Is
the
water
from
these
wells
treated
by
your
system?

(
Yes
or
No)
What
is
the
total
amount
of
water
drawn
from
these
wells
in
the
12
month
period
reported
in
question
2A?

(
MG)
On
average,
how
much
water
is
drawn
from
these
wells
on
a
typical
day
that
they
were
used
during
the
reporting
period
in
question
2A?

(
MGD)
Estimate
the
maximum
daily
amount
of
water
that
can
be
drawn
from
the
wells
that
supply
each
ground
water
entry
point.
1
(
MGD)

G1
G2
G3
G4
G5
G6
G7
G8
G9
G10
1.
If
there
is
no
limit
on
the
amount
of
water
that
can
be
withdrawn,
enter
"
no
limit"
here.

Limits
on
the
availablity
of
water
include
source
capacity,
contractual
obligations,
permits,
water
rights,
and
legal
constraints.

Limits
also
include
current
equipment
constraints
imposed
by
system
components,
pumps,
and
water
treatment
plant
capacity.

DRAFT
6
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
B.
Surface
water
intake
identifiers.

What
is
the
source
for
each
surface
water
intake?

(
Please
select
one)

1)
Flowing
stream,

2)
Reservoir
or
lake,

3)
GWUDI
1
S1
S2
S3
S4
S5
S6
S7
S8
S9
S10
1.
GWUDI
is
ground
water
under
the
direct
influence
of
surface
water.

2.
If
there
is
no
limit
on
the
amount
of
water
that
can
be
withdrawn,
enter
"
no
limit"
here.

Limits
on
the
availablity
of
water
include
source
capacity,
contractual
obligations,
permits,
water
rights,
and
legal
constraints.

Limits
also
include
constraints
imposed
by
system
components,
pumps,
and
water
treatment
plant
capacity.
Estimate
the
maximum
daily
amount
of
water
that
can
be
drawn
from
each
surface
water
intake.
2
Is
the
water
from
this
intake
treated
by
your
system?

(
Yes
or
No
)
What
is
the
total
amount
of
water
drawn
from
this
source
in
the
12
month
period
reported
in
question
2A?

(
MG)

Surface
water
intake
identifiers
If
this
is
a
seasonal
or
emergency
source,
how
many
months
was
it
used
in
the
12
month
period
reported
in
question
2A?

Is
this
a
seasonal
source?

(
Yes
or
No
)
On
average,
how
much
water
is
drawn
from
this
source
on
a
typical
day
that
it
was
used
during
the
reporting
period
in
question
2A?

(
MGD)

Is
this
an
emergency
source?

(
Yes
or
No
)

DRAFT
7
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
C.
Purchased
water
connections.
When
you
purchase
this
water,
is
it
one
of
the
following?

(
Please
select
one):
What
is
the
source
of
the
purchased
water?

(
Please
select
one)

1)
Finished,

2)
Partially
treated,

3)
Untreated,

4)
Unknown
1)
Ground,

2)
Surface,

3)
GWUDI
1
4)
Unknown
P1
P2
P3
P4
P5
P6
P7
P8
P9
P10
1.
GWUDI
is
ground
water
under
the
direct
influence
of
surface
water.

2.
If
there
is
no
limit
on
the
amount
of
water
that
can
be
withdrawn,
enter
"
no
limit"
here.

Limits
on
the
availablity
of
water
include
source
capacity,
contractual
obligations,
permits,
and
legal
constraints.

Limits
also
include
constraints
imposed
by
system
components,
pipeline
carrying
capacity,
and
water
treatement
plant
capacity.
Estimate
the
maximum
daily
amount
of
water
that
can
be
drawn
from
each
purchased
water
connection.
2
Do
you
boost
disinfection
of
water
from
this
source
after
it
enters
the
distribution
system?

(
Yes
or
No)
What
is
the
total
amount
of
water
drawn
from
this
source
in
the
12
month
period
reported
in
question
2A?

(
MG)
On
average,

how
much
water
is
drawn
from
this
connection
on
a
typical
day
that
it
was
used
during
the
reporting
period
in
question
2A?

(
MGD)

Do
you
provide
any
other
treatment
to
this
water?

(
Yes
or
No
)

Purchased
water
connections
Provide
the
PWSIDs
or
name
of
the
sellers
for
each
connection.

A
seller
can
appear
more
than
once.
Is
this
a
seasonal
source?

(
Yes
or
No)
If
this
is
a
seasonal
or
emergency
source,
how
many
months
was
it
used
in
the
12
month
period
reported
in
question
2A?

Is
this
an
emergency
source?

(
Yes
or
No)

DRAFT
8
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
7
Provide
the
following
information
for
each
water
treatment
plant
in
this
water
system.
A
water
treatment
plant
is
any
facility
that
treats
or
otherwise
improves
the
quality
of
the
water.
It
includes
large
scale
filtration
plants,
chemical
feed
on
wells
for
disinfection,
and
facilities
that
adjust
pH
prior
to
entry
to
the
distribution
system.
It
does
not
include
facilities
within
the
distribution
system
that
boost
disinfection.

Average
daily
production
is
the
total
amount
of
water
produced
by
the
plant
divided
by
the
number
of
days
the
plant
was
in
use
in
the
twelve
month
reporting
in
question
2A.
Mathematically,
it
is
the
sum
of
all
the
daily
flows
divided
by
the
number
of
daily
flows.
Design
capacity
refers
to
the
maximum
amount
of
water
the
plant
can
produce
in
a
single
24
hour
period
with
all
treatment
trains
operating
at
capacity.
Peak
daily
production
refers
to
the
maximum
amount
produced
in
a
single
day
over
the
twelve
month
reporting
period
in
question
2A.

Water
treatment
plant
identifier
List
all
of
the
surface,
ground,
and
purchased
water
sources
from
question
6
that
feed
into
each
water
treatment
plant.
What
was
the
average
daily
production
of
each
water
treatment
plant
for
the
twelve
month
period
reported
in
question
2A?
What
was
the
design
capacity
for
each
water
treatment
plant
for
the
twelve
month
period
reported
in
question
2A?
What
was
the
peak
daily
production
for
each
water
treatment
plant
for
the
twelve
month
period
reported
in
question
2A?

WTP1
WTP2
WTP3
WTP4
WTP5
WTP6
WTP7
WTP8
WTP9
WTP10
DRAFT
9
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
Use
the
treatement
processes
in
table
1
and
the
objectives
in
table
2
to
describe
the
treatement
prceseds
used
by
each
plant
in
question
9.

Table
1:
Treatment
Processes
Codes
Table
2:
Treatment
Objectives
Codes
Treatment
Code
Treatment
Code
Treatment
Code
Disinfection
Filtration
(
continued)
Algae
control
O1
Chlorine
T1
Rapid
sand
single
media
T24
Corrosion
control
O2
Chlorine
dioxide
T2
Rapid
sand
dual/
multi­
media
T24
Primary
disinfection
O3
Chloramines
only
T3
Rapid
granular
single
media
T25
Residual
disinfection
O4
Chloramines
with
free
Rapid
granular
dual/
multi­
media
T26
Dechlorination
O5
chlorine
burnout
period
T4
Oxidation
O6
Chloramines
and
free
Membranes
Iron
removal
O7
chlorine
seasonally
T5
Reverse
osmosis
T27
Manganese
removal
O8
Ozone
T6
Microfiltration
T28
Taste/
odor
control
O10
Ultra
violet
T7
Ultrafiltration
T29
TOC
removal
O11
Potassium
Permanganate
T8
Nanofiltration
T30
Particulate/
Turbidity
Removal
O12
Softening
(
hardness
removal)
O13
Aeration
T9
Other
Recarbonation
O14
Coagulant
Addition/
Rapid
Mix
T10
Corrosion
control
T31
Organic
chemical
contaminant
removal
(
e.
g.,
VOCs,
pesticides)
O15
Flocculation
T11
Ion
exchange
T32
Inorganic
chemical
contaminant
removal
(
e.
g.,
arsenic)
O16
Settling/
sedimentation
T12
Activated
alumina
T33
Radionuclides
contaminant
removal
O17
Lime/
soda
ash
softening
T13
Iron­
based
adsorptive
media
T34
Security
O18
Polymers
T14
Sequestration
T35
Ion
exchange
T15
Fluoride
addition
T36
Other
(
1)
O19
Recarbonation
T16
Dissolved
air
flotation
T37
Other
(
2)
O20
Granular
activated
carbon
T38
Other
(
3)
O21
Filtration
Centrally
managed
POU/
POE
T39
Micro
strainer
T17
Clearwell
T40
Slow
sand
filter
T18
Bag
and
cartridge
T19
Other
(
1)
T41
Diatomaceous
earth
T20
Other
(
2)
T42
Pressure
filtration
T21
Other
(
3)
T43
Green
sand
T22
DRAFT
10
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
8
Using
the
water
treatment
plant
identifiers
from
question
7,
characterize
the
treatment
practices
used
in
each
of
your
system's
treatment
plants.

­
Please
enter
the
treatment
process
and
objective
for
each
step
of
the
treatment
practice.
Use
the
codes
from
tables
1
and
2
above.

­
There
are
a
total
of
15
steps
available
to
select
these
processes
and
objectives.
Each
step
may
have
up
to
three
processes
and
objectives.
Copy
this
page
if
you
have
more
than
10
plants
or
use
more
than
15
steps
in
a
single
plant.

­
Do
not
include
disinfection
booster
stations
that
are
within
the
distribution
system.

Step
1
Step
2
Step
3
Step
4
Step
5
Step
6
Step
7
Step
8
Step
9
Step
10
Step
11
Step
12
Step
13
Step
14
Step
15
Process
T9
T1
T8
T12
T22
T40
T3
Objective
O3
O6
O12
O4
Process
Objective
Process
Objective
Process
Objective
Process
Objective
Process
Objective
Process
Objective
Process
Objective
Process
Objective
Process
Objective
Process
Objective
Use
treatment
codes
T41,
T42,
and
T43
for
any
treatment
process
you
use
Use
treatment
codes
O19,
O20,
and
O21
for
any
objective
that
is
not
listed.
Please
specify
what
each
process
is:
that
is
not
listed.
Please
specify
what
each
objective
is:

T41:
Other
(
1)
O19:
Other
(
1)

T42:
Other
(
2)
O20:
Other
(
2)

T43:
Other
(
3)
O21:
Other
(
3)

WTP
8
WTP
9
WTP
10
WTP
4
WTP
5
WTP
6
WTP
7
WTP
WTP
1
WTP
2
WTP
3
Example
DRAFT
11
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
9
Using
the
water
treatment
plant
identifiers
from
question
7,
indicate
if
the
specified
residuals
management
practices
are
used
and
provide
the
requested
information
regarding
potential
discharge.
(
Yes
or
No
for
each
category)

Do
you
use
the
following
residual
management
process
in
the
following
water
treatment
plants?

(
use
the
water
treatment
plant
numbers
from
Question
8)

Dewatering
Disposal
Waste
landfill
Waterway
Septic
system
Sanitary
sewer
Water
treatment
plant
identifier
Hazardous
waste
landfill
Nonhazardous
waste
landfill
Can
you
discharge
to
a
waterway
(
surface
water)?
If
yes,
do
you
discharge
to
a
waterway?
Can
you
discharge
to
a
septic
system?
If
yes,
do
you
discharge
to
a
septic
water
source?
Can
you
discharge
to
a
sanitary
sewer?
If
yes,
do
you
discharge
to
a
sanitary
sewer?

WTP
1
WTP
2
WTP
3
WTP
4
WTP
5
WTP
6
WTP
7
WTP
8
WTP
9
WTP
10
Deep
well
injection
Mechanical
dewatering
(
e.
g.
belt
presses,
centrifuges,

pressure
filters,
and
vacuum
filters)
Nonmechanical
dewatering
(
e.
g.,
lagoons,

drying
beds,

and
freeze
assisted
drying
beds)
Land
application
(
e.
g.,
beneficial
use)

DRAFT
12
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
[
QUESTION
11
ASKED
OF
VERY
LARGE
SYSTEMS
ONLY]

10
A
Is
your
system
currently
treating
(
directly
or
indirectly)
for
any
contaminants
not
regulated
by
the
federal
government?
(
Directly
means
that
the
treatment
in
place
is
due
to
the
presence
of
the
unregulated
contaminant.
Indirectly
means
that
the
unregulated
contaminant
is
being
addressed
because
of
current
treatment
practices
for
a
regulated
contaminant).

Yes
No
(
Skip
to
question
11)

B
Please
provide
the
following
information
about
unregulated
contamaninants
addressed
by
your
treatment
plants.

If
known,
please
provide
the
concentration
of
the
unregulated
contaminant
in
the
raw
and
finished
water
as
it
leaves
the
plant.
Enter
N/
A
if
unknown.
Enter
ND
if
the
contaminant
was
not
detected.
Please
provide
the
units
as
well
(
e.
g.,

mg/
L).

Raw
water
Finished
Water
Concentration
Units
Concentration
Units
What
water
treatment
plant
treats
for
the
unregulated
contaminant
(
use
plant
identifiers
from
questions
8)?

What
are
the
unregulated
contaminants
that
are
being
addressed
by
your
treatment
plants?
Is
the
plant
treating
directly
for
this
contaminant,
i.
e.,
is
it
in
place
to
treat
specifically
for
this
contaminant?

DRAFT
13
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
11
A
List
the
storage
vessels
in
the
distribution
system.
If
you
have
more
than
10
B
Do
you
use
any
of
the
following
practices
to
maintain
water
quality
vessels,
copy
this
page
and
provide
the
information
for
additional
tanks.
Use
the
in
storage
vessels
in
your
system?
(
Check
all
that
apply)

definitions
of
vessel
type
and
arrangement
of
inlets
and
outlets
that
are
in
the
table
below.
Fully
or
partially
buried
500,000
5
4
2.5
Common
inlet
and
Types
of
vessels
include:
Arrangements
of
inlets
and
outlets
1
Fully
or
partially
buried
1
Common
inlet
and
outlet
2
Ground
level
2
Separate
inlet
and
outlet
3
Elevated
3
Baffled
4
Hydro­
pneumatic
4
Mixed
5
Standpipes
5
Other
6
Other
Increase
or
switch
disinfectant
residual
Modeling
or
other
detention
time
evaluations
Longer
fill/
draw
cycles
to
increase
mixing
Inlet/
outlet
modifications
Mechanical
mixing
ST
8
ST
9
ST
10
Operational
modifications
to
maintain
disinfectant
residual
ST
4
ST
5
Other
(
please
specify)

ST
6
ST
7
St
Example
ST
1
ST
2
ST
3
Vessel
What
is
the
physical
arrangement
of
inlets
and
outlets?

Type
of
vessel
Volume
of
vessel
(
gallons)
What
is
the
frequency
of
cleaning
(
typical
number
of
years
between
cleanings)
What
is
the
typical
detention
time
of
the
water
in
the
vessel
(
in
days)?

Winter
Months
Summer
Months
DRAFT
14
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
12
Estimate
the
length
of
the
transmission
lines
and
distribution
mains
in
your
system,
and
length
of
pipe
replaced
in
the
last
five
years.

Replaced
pipe
is
pipe
that
has
either
been
physically
removed
from
the
ground
or
has
had
major
rehabilitation
efforts
done
to
it.

A
transmission
line
is
defined
as
a
pipeline
that
transports
raw
or
partially
treated
water
to
a
water
treatment
plant
or
finished
water
to
a
distribution
grid.

A
distribution
main
is
defined
as
part
of
the
pipeline
network
that
distributes
water
to
the
consumers.
Distribution
System
Transmission
Line
Transmission
Line
6"
8"
Greater
than
10"
and
Less
than
24"

1.
Ending
on
the
date
shown
in
your
answer
to
question
2A.
Water
Treatment
Plant
Source
Less
than
6"

10"

24"
or
greater
Transmission
lines
Pipe
Type
and
Diameter
Mains
Length
of
Pipe
(
In
Miles)
Length
of
Pipe
Replaced
in
the
Last
5
Years
1
(
In
Miles)

DRAFT
15
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
13
A
Please
provide
the
following
information
about
each
pressure
zone
in
your
distribution
system.

1
How
many
pressure
zones
do
you
have
in
your
distribution
system?

2
How
many
pressure
zones
have
booster
disinfection
stations?

3
How
many
booster
disinfection
stations
do
you
have
throughout
your
distribution
system?

4
a
What
is
the
typical
minimum
daily
operating
pressure
across
all
the
pressure
zones
in
your
system?

b
What
is
the
typical
maximum
daily
operating
pressure
across
all
the
pressure
zones
in
your
system?

B
If
your
system
has
experienced
a
loss
of
pressure
during
the
past
operating
year
below
the
minimum
listed
in
part
A
of
this
question,
please
tell
us
the
number
of
pressure
losses
that
occurred
for
each
of
the
following
reasons:

1
Power
outage
2
Fire
3
Main
pipeline
burst
4
Other
(
such
as
maintenance,
flushing;
please
specify)

14
Do
you
flush
your
distribution
system
on
a
regular
basis?

Yes
No
(
If
No,
skip
to
question
17)

15
What
percentage
of
the
distribution
system
is
flushed
each
year
on
a
regular
basis?
%

16
What
approach
is
used
when
you
flush
your
system
on
a
regular
basis?

A
Directional
(
restricting
the
direction
water
can
flow)

B
Random
(
opening
hydrants
on
lines
without
closing
valves
or
restricting
the
direction
of
water
flow)

C
Dead
end
(
opening
a
hydrant
or
flush
valve
on
the
dead
end
line)

D
Other
(
specify)

17
A
If
you
do
not
flush
your
system
on
a
regular
basis,
have
you
ever
flushed
your
system?

Yes
No
(
If
No,
skip
to
question
18)

B
1
What
was
the
last
year
you
flushed
your
system?

2
What
year
did
you
flush
the
system
before
that?

DRAFT
16
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
(
Enter
"
NA"
if
you
only
flushed
the
system
once).

DRAFT
17
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
18
Please
provide
the
following
data
on
disinfection
residuals
for
one
summer
month
(
June,
July,
August,
September)
and
one
winter
month
(
December,
January,
February).
Average
Entry
Point
Disinfectant
Residual
for
the
Treatment
Plant
with
the
Highest
Average
Daily
Flow
(
mg/
L)
Distribution
system
Surface
water
entry
point
1
Ground
water
entry
point
Average
distribution
disinfectant
residual
(
mg/
L)

(
mg/
L
as
CL2)
(
mg/
L
as
CL2)
(
mg/
L
as
CL2)

Season
Month
Total
CL2
Free
CL2
Total
CL2
Free
CL2
Total
CL2
Free
CL2
Total
CL2
Summer
%

Winter
%

1.
Surface
water
entry
points
includes
ground
water
under
the
direct
influence
of
surface
water.
If
the
plant
treats
both
surface
and
ground
water,

report
the
results
in
the
surface
water
entry
points
columns.

[
QUESTIONS
19
ASKED
OF
SMALL
AND
MEDIUM
SYSTEMS
ONLY]

19
Please
list
the
5­
digit
ZIP
codes
included
in
your
service
area
Percentage
of
Distribution
System
Samples
<
0.2
mg/
L,

including
nondetects
DRAFT
18
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
20
Please
answer
the
following
questions
about
water
security.
Enter
Yes
or
No
A
1
Has
your
water
system
attended
any
EPA
sponsored
water
security
training?

2
Have
you
used
EPA's
web­
based
water
security
technology
product
guides?

3a
Do
you
have
sufficient
information
to
prevent,
detect,
respond
to,
and
recover
from
security
incidents
at
your
water
system?

3b
If
"
no,"
what
information
is
lacking?
__________________________________________________________________________________

4
Have
you
heard
of
EPA's
Response
Protocol
Toolbox?

5
Have
you
heard
of
the
14
features
of
an
"
active
and
effective"
water
security
program?

B
1
Have
you
heard
of
mutual
aid
and
assistance
agreements
and/
or
compacts?
(
If
no,
skip
to
section
C)

2
Would
you
be
interested
in
joining
such
an
agreement
and/
or
compact?

3
If
not,
please
answer
why
not
______________________________________________________________________________________

C
What
are
the
two
largest
barriers
to
enhancing
security
at
your
system?
(
Please
select
only
2)

1
Lack
of
interest
at
they
system,
public,
or
rate
board
level
2
Competing
priorities
(
regulatory
compliance,
aging
infrastructure,
etc.)

3
Lack
of
funding
4
Lack
of
knowledge/
guidance
/
training
materials
5
Other
(
Please
specify)

D
Who
do
you
prefer
to
get
Water
Security
Information/
Products
from?
(
pick
one)

1
Department
of
Homeland
Security
2
EPA
3
Water
Associations
4
Other
(
Please
specify)

DRAFT
19
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
21
A
Please
complete
the
table
below
for
the
12­
month
period
indicated
in
question
2b,
B
Please
indicate
your
water
system's
revenue
during
the
last
following
the
instructions
for
each
of
the
four
columns.
year
from
other
water­
related
revenue
sources.

Column
A:
What
was
the
amount
of
water
that
was
produced
and
delivered
to
each
of
1
Connection
and
development
fees
$

the
following
customer
categories?
Report
the
amount
in
millions
of
gallons
per
year
2
Revenue
from
the
Government
(
e.
g.
General
(
MGY).
Unaccounted
for
water
includes
system
losses
and
uncompensated
uses
fund
of
Municipal
Government,
public
(
e.
g.,
fire
flow).
systems
only):
$

3
Other
water­
related
revenue
not
reported
Columns
B
and
C:
How
many
connections
and
people
did
your
drinking
water
above
(
e.
g.,
fines,
penalties,
other
fees.
$

system
serve
year­
round?
Please
indicate
the
number
of
connections
and
number
of
Please
specify
)

people
served
by
your
water
system
for
all
customer
types
that
apply.

Column
D:
What
were
your
drinking
water
system's
revenues
from
water
sales
for
each
of
the
following
customer
categories?
(
Enter
"
0"
if
you
do
not
have
revenue
C
Provide
the
PWSID
or
name
of
each
public
water
supplier
from
a
source.)
included
in
the
response
to
part
A1
above.

Column
A
Column
B
Column
C
Column
D
1
Finished
water
Water
Number
of
Number
of
Water
Quantity
Connections
People
Sales
Delivered
Served
Served
Revenue
1
Sold
to
other
water
suppliers
a
Finished
water
MGY
$

b
Partially­
treated
or
untreated
water
MGY
$
2
Partially­
treated
or
untreated
water
2
Residential
MGY
$

3
Non­
residential
(
Commercial,
Industrial,
Agricultural)

a
Finished
water
MGY
$

b
Partially­
treated
or
D
Please
indicate
the
revenue
you
receive
from
untreated
water
MGY
$
non­
drinking
water
related
business,
not
included
above,
including
rental
income
and
the
4
Unaccounted
for
water
MGY
sale
of
other
goods
and
services:
$

DRAFT
20
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
22
Please
identify
your
drinking
water
system's
billing
structure
[
QUESTIONS
24
ASKED
OF
SMALL,
MEDIUM,
SYSTEMS
ONLY]

(
check
all
that
apply).
Non­
24
A
Does
your
system
serve
a
residential
population
that
changes
on
a
Residential
residential
seasonal
basis?
The
seasonal
population
is
considered
the
population
A
Metered
charges
Customers
Customers
that
fluctuates
within
a
system
based
on
the
seasons.
For
example,
the
1
Uniform
rate
population
of
a
water
system
serving
a
winter
or
summer
resort
area
has
2
Declining
block
rate
an
influx
during
certain
periods
of
the
year.
(
Please
check
Yes
or
No
)

3
Increasing
block
rate
Yes
4
Peak
period
rate
(
e.
g.,
seasonal)
No
(
Skip
to
question
25)

B
Unmetered
charges
5
Separate
flat
fee
for
water
6
Annual
connection
fee
7
Combined
flat
fee
for
water
25
Please
enter
the
average
number
of
hours
operators,
mangers,
and
and
other
services
(
e.
g.,
rental
feeds,
administrative
staff
work
in
the
water
system
each
week.
Please
include
association
fees,
pad
fees):
contract
employees
that
operate
the
system.
For
staff
employed
directly
by
C
Other
billing
methods
(
please
specify
):
the
system,
enter
the
average
hourly
wage
or
salary
of
each.
Enter
the
cost
of
fringe
benefits
provided
as
a
percentage
of
wages
or
salaries.
(
Fringe
benefits
include
pension
and
other
retirement
contributions,
health
insurance
23
A
Does
your
system
have
a
program
that
lowers
the
cost
of
drinking
water
contributions,
vacation
and
sick
leave.)
For
contract
employees
that
operate
for
low­
or
fixed­
income
households?
(
Please
check
one)
the
system,
provide
the
average
hourly
cost
to
the
system
of
the
contract
employees
(
inlcuding
wages,
salaries,
benefits,
and
fees).

Yes
No
(
Go
to
question
33)
Contract
employees
B
What
are
the
eligibility
requirements
for
this
program?
Hours
per
that
operate
week
Employees
of
the
system:
the
system
employees
Benefits
as
a
work
in
the
Average
percentage
Average
water
hourly
of
salary
or
hourly
labor
Staff
system
wage/
salary
wages
cost
A
Operators
$
%
$

C
How
many
households
qualify
B
Managers
$
%
$

for
the
program?
C
Administrative
staff
$
%
$

Please
indicate
the
highest
seasonal
number
of
residential
connections.

B
DRAFT
21
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
26
This
question
is
intended
to
account
for
all
of
your
drinking
water
expenses
27
A
If
you
have
paid
for
major
capital
improvements,
repairs,
or
related
to
the
revenues
referred
to
in
question
21
A
and
B.
expansions
in
the
last
five
years
ending
on
the
date
reported
in
question
2b,
please
indicate
the
total
amount
spent
on
these
capital
A
Please
attach
available
summaries
of
financial
statements,
including
a
expenditures
balance
sheet,
income
statement,
and
statement
of
cash
flows.
Please
attach
a
depreciation
schedule,
if
one
is
available.
(
I.
e.,
a
program
defining
1
a
Land:
$

your
process
for
depreciating
the
value
of
capital
improvements.)
b
How
much
land
was
purchased
(
acres):

B
Please
enter
the
following
routine
operating
expenses
in
the
last
year:
2
Water
source:
$

1
Expenses
for
purchased
water:
$
3
Transmission
and
distribution
system:
$

2
Security
related
expenses
(
spending
for
security
only,
e.
g.,
gates,
locks,
or
guards)
$
4
Treatment
$

3
Other
routine
operating
expenses
(
including
5
Storage
$

expenses
for
labor,
chemicals,
power,
materials
and
supplies,
and
contractor
services):
$
6
Security
(
include
security­
related
spending
not
included
in
other
capital
4
Depreciation
expenses:
$
expenditures)
$

5
Income
taxes
(
privately
owned
systems):
$
7
All
other
not
included
above:
$

6
Payments
in
lieu
of
taxes
and
other
payments
B
What
percentage
of
the
total
capital
expenditures
identified
in
part
A
to
the
general
fund
(
publicly
owned
systems):
$
were
used
for
the
following
(
must
sum
to
100
percent):

C
Please
enter
the
amount
of
debt
service
expenditures
in
the
last
year:
1
System
expansion,
regardless
of
whether
expenditure
includes
replacement
and
repair
7
Interest
payments:
$
of
equipment
or
compliance
with
requlations
%

8
Principal
payments:
$
2
Replacement
and
repair
of
equipment,
regardless
of
whether
it
includes
compliance
with
regulations
D
Other
Expenses
but
excluding
spending
for
system
expansion
%

9
Capital
improvements:
$
3
Compliance
with
regulations,
excluding
expenditures
for
system
expansion
and
replacement
10
Payments
to
reserve
funds:
$
and
repair
of
equipment
%

DRAFT
22
DRAFT
DRAFT
CWSS
2006
Questionnaire
DRAFT
C
How
were
the
total
expenses
from
question
35A
funded?
Percentage
of
capital
expenses
For
borrowed
funds,
please
provide
the:

funded
from
each
source
(
should
sum
to
100
percent)
Average
Interest
Rate
Average
Length
of
Loan
Period
(
Years)

1
Current
revenue
(
including
payments
from
reserve
funds):
%

2
Equity
or
other
funds
from
private
investors
%

3
Department
of
Homeland
Security
Grant
%

4
Other
government
grants:
%

5
Drinking
Water
State
Revolving
Fund
a
Principal
Repayment
Forgiveness:
%

b
Loans
%
%

6
Other
borrowing
from
public
sector
sources
(
e.
g.,
state
or
regional
authorities):
%
%

7
Borrowing
from
private
sector
sources
(
e.
g.,
banks
or
the
bond
market):
%
%

8
Other
(
please
specify):
%
%

28
A
Do
you
have
an
asset
management
plan
or
other
formal
written
strategy
addressing
your
long­
term
(
e.
g.,
20
years
or
more)
needs
for
infrastructure
rehabilitation
and
replacement?

Yes
No
DRAFT
23
DRAFT
