SMALL WATER SYSTEM
2013 ANNUAL REPORT TO THE DRINKING WATER PROGRAM
FOR YEAR ENDING DECEMBER 31, 2013
[Section 116530 Health & Safety Code]

WATER SYSTEM INFORMATION
Water System No.:
Water System Name:
Water System Classification:
Water System Ownership (See descriptions below):	--Pick one-- Local Government State or Federal Government Privately owned, PUC-regulated, for profit water company Privately owned, non-PUC-regulated (Community Water System) Privately owned Mutual Water Company or Association Privately owned business (non-community)
Physical location:   (address line 1, address line 2, city, zip)
General Office Phone: (with area code)
Web site address:

Water System Ownership Descriptions:

• Local Government: e.g., city, county, or special district, local school district, junior colleges, county or community parks, etc.
• State or Federal Government: e.g., state or national park, BLM, USFS and COE campgrounds and recreation facilities,
  state hospitals, State universities and colleges, California Veterans Home, County or District Fairs and Expositions,
  Caltrans rest stop, military base, other state or federal facility
• Privately owned, non-PUC-regulated (Community Water System): e.g., mobile home park, apartment or condominium
• Privately owned business (non-community): e.g., church, private school, restaurant, amusement park, RV park/campground,
  motel, ranch/farm, factory, other business establishment

REPORT SUBMITTED BY:
Name:
Title:
Business phone:
Cell phone:
Email address:

COMMENTS:

1. Public Water System Contacts

Click here to learn how to Modify, Add and Delete Contacts in the table below.

NAME, TITLE & ADDRESS			PHONE TYPE	PHONE NO.	EMAIL	CONTACT TYPE (pick all that apply)
			Business			** Delete Contact ** Administrative	Operator
			Facsimile			Financial	Emergency
			Mobile			Designated Operator In Charge	Water Quality
			Emergency			Owner	Legal
			Business			** Delete Contact ** Administrative	Operator
			Facsimile			Financial	Emergency
			Mobile			Designated Operator In Charge	Water Quality
			Emergency			Owner	Legal
			Business			** Delete Contact ** Administrative	Operator
			Facsimile			Financial	Emergency
			Mobile			Designated Operator In Charge	Water Quality
			Emergency			Owner	Legal
			Business			** Delete Contact ** Administrative	Operator
			Facsimile			Financial	Emergency
			Mobile			Designated Operator In Charge	Water Quality
			Emergency			Owner	Legal
			Business			** Delete Contact ** Administrative	Operator
			Facsimile			Financial	Emergency
			Mobile			Designated Operator In Charge	Water Quality
			Emergency			Owner	Legal
			Business			** Delete Contact ** Administrative	Operator
			Facsimile			Financial	Emergency
			Mobile			Designated Operator In Charge	Water Quality
			Emergency			Owner	Legal
			Business			** Delete Contact ** Administrative	Operator
			Facsimile			Financial	Emergency
			Mobile			Designated Operator In Charge	Water Quality
			Emergency			Owner	Legal
			Business			** Delete Contact ** Administrative	Operator
			Facsimile			Financial	Emergency
			Mobile			Designated Operator In Charge	Water Quality
			Emergency			Owner	Legal
Add Additional Contact						(pick all that apply)
			Business			Administrative	Operator
			Facsimile			Financial	Emergency
			Mobile			Designated Operator In Charge	Water Quality
			Emergency			Owner	Legal
Add Additional Contact						(pick all that apply)
			Business			Administrative	Operator
			Facsimile			Financial	Emergency
			Mobile			Designated Operator In Charge	Water Quality
			Emergency			Owner	Legal

COMMENTS:

2. POPULATION SERVED

Population Type	Population	Annual Operating Period
			Begin Date		End Date
			MM	DD	MM	DD
Residential1		Method Used to Determine Population:    --Pick one-- Most recent United States census data Multiplied number of service connections by 3.3 Determined total number of dwelling units and multiplied by 2.8 Other
Transient2
Nontransient3

MM = month, in 2-digit format DD = day, in 2-digit format

Descriptions:

¹Residential – report the number of persons who reside within the water system service area for more than half of the year (excludes
transient and nontransient populations). If year-round, the Begin Date would be 01/01 and the End Date would be 12/31.

²Transient – report the number of persons who are at the water system on the 60^th busiest day of the year (excludes residential and nontransient
populations. Report the Begin Date and End Date if the Transient use is seasonal.

³Nontransient – report the number of the persons who are at the water system for over 6 months per year (excludes residential and
transient populations). Report the Begin Date and End Date if the Nontransient use is seasonal.

List the names of communities served by the system identifying both incorporated and unincorporated areas:

COMMENTS:

3. NUMBER OF SERVICE CONNECTIONS(as of December 31, 2013)

A. Active Service Connections:

Total Active Potable Water Connections currently in CDPH database:

The total number of Service Connections as of December 31, 2013 must be reported as either Unmetered or Metered for each Service Connection Type as appropriate.

	Potable Water			Recycled Water
TYPE Do NOT report fire sprinkler connections. These connections are not counted toward “service connections” for compliance purposes.	Unmetered	Metered	Total*	Unmetered	Metered	Total*
Single-family Residential: single family detached dwellings
Multi-family Residential: duplexes, town homes, condominiums, apartments, and trailer parks
Commercial/Institutional: hotels, schools, prisons, hospitals, nursing homes, dormitories, laundries, retail establishments (malls, shopping centers, retail stores, service shops, restaurants), office buildings, gas stations
Industrial: industrial parks, manufacturing, warehouses, utilities, assemblers
Landscape Irrigation: Play fields, golf courses, roadways, median strips, cemeteries, parks and other dedicated landscape connections
Agricultural Irrigation: irrigation of commercially-grown crops and other dedicated agricultural connections
Other (services that do not meet any of the above definitions): This service connection type is intended to be used by noncommunity systems such as churches, businesses, county, state and national parks, schools and other public institutions that operate as an individual public water system and do not specifically have connections for which water rates are charged.
Total Active Connections*

*Calculated field

B. Number of Inactive Connections (all types)

COMMENTS:

4. GROUNDWATER (GW) AND SURFACE WATER (SW) SOURCES

GROUNDWATER SOURCES (INCLUDING STANDBY SOURCES)

PSCode	Name	Activity

SURFACE WATER INTAKES

PSCode	Name	Activity

DISCUSS CHANGES TO ABOVE SOURCES

If a STANDBY SOURCE was used in 2013, provide the following information.

Name of the Standby Source used in 2013:	No. of days the Standby Source was in operation:	Were customers notified? (Y/N)	Was CDPH or Local County Staff notified? (Y/N)	Describe the reason the Standby Source was used:
					1 - 4 of 4

COMMENTS:

5. WATER PRODUCED, PURCHASED AND SOLD

The Maximum Day is the day during 2013 with the highest total water usage. Provide the date for that day in Column B,
then complete Columns C, D and E, indicating how much of the water on that day was from each source.

The Maximum Month is the month during 2013 with the highest total water usage. Provide the month in Column B,
then complete Columns C, D and E, indicating how much of the water during that month was from each source.

Units of Measure for this table: --Pick one-- Gallons Million Gallons Acre-feet (AF) 100 cubic feet

Volumes are based on: --Pick one-- METERED VOLUMES ESTIMATED VOLUMES

A	B	C	D	E	F	G	H	I
	Potable Water						Non-potable (exclude recycled)	Recycled
	Date/ Month	Water Produced from Groundwater (Wells)	Water Produced from Surface Water2	Finished Water Purchased or Received from another PWS5	Total Amount of Potable Water3*	Water Sold to Another PWS5
Maximum Day1
Maximum Month
January
February
March
April
May
June
July
August
September
October
November
December
Annual Total*
Percent Treated4

PWS = Public Water System

^*Calculated field

Non-potable = water supplies that do not enter the drinking water distribution system and are for non-potable uses only such as irrigation or toilet flushing

¹Only report Maximum Day if it is actually measured or determined from production records. It should not be the average day demand during
the maximum month of production.

²Do not include raw water purchased; report only volume of water that was treated.

³(F) Total Amount of Potable Water = Sum of Columns (C), (D) and (E), automatically calculated. To update, click below

⁴This is the percentage of the total annual volume for Groundwater produced that was provided treatment to meet drinking water standards other than precautionary disinfection.

⁵If water was Purchased from or Sold to another PWS, complete the table below:

Specify whether water was Purchased or Sold	Name of PWS
		1 - 3 of 3

If recycled water was supplied to your customers, complete the table below:

Specify the level of treatment (e.g., tertiary, disinfected secondary)	Name of Recycled Water supplier
		1 - 3 of 3

COMMENTS:

6a. WATER RATES

Indicate the type of water rate structure used by your water system: --Pick one-- Flat Base Rate Uniform Usage Rate Variable Base Rate Variable usage Rate Flat Base Rate + Uniform Usage Rate Flat Base Rate + Variable Usage Rate Variable Base Rate + Variable Usage Rate Other Rate Structure (specify rate structure used in the Comments box) We Do Not Charge A Water Rate (specify why in the Comments box)

What is your billing frequency --Pick one-- monthly bi-monthly other

Complete the table below providing specific water rates applied to your customers:

Connection Type	FLAT BASE RATE	UNIFORM USAGE RATE	VARIABLE BASE RATE (provide range)		VARIABLE USAGE RATE (provide range)
	$ (Base)	$ per hcf	$ Low	$ High	$ per hcf Low	$ per hcf High
RESIDENTIAL
Single-family Residential
Multi-family Residential
Do you provide lifeline/low income subsidies? --Pick one-- Yes No
If Yes, provide rates:
NON-RESIDENTIAL
Commercial/Institutional
Industrial
Landscape Irrigation
Agricultural Irrigation
Other
Do you have fire suppression surcharges? --Pick one-- Yes No
If Yes, provide rates:
Do you have other surcharges? --Pick one-- Yes No
If Yes, provide rates:

AVERAGE MONTHLY RESIDENTIAL WATER COST: $/mo.

This value can be calculated by dividing your total annual revenues from residential customers by 12 and then dividing a second time by the number
of residential service connections. If you are unable to differentiate revenues by type of customer {residential, industrial, agricultural}; then take your
total annual revenues from all water rate payments and divide by 12 and then divide by your total number of service connections.

NOTE: If this is not a "Community" Water System; enter N/A. If individual customers do not pay a separate bill for water enter "0".

6b. WATER DELIVERIES

Units of Measure for this table: --Pick one-- Gallons Million Gallons Acre-feet (AF) 100 cubic feet

Provide monthly metered water deliveries in the table below.

A	B	C	D	E	F	G	H	I	J
	Single-family Residential	Multi-family Residential	Commercial/ Institutional	Industrial	Landscape Irrigation	Other	Total Urban Retail1*	Agricultural	Other PWS
Check if Recycled Water is included:
January
February
March
April
May
June
July
August
September
October
November
December
Total*

PWS = Public Water System

^*Calculated field

¹Total Urban Retail = Sum of Columns (B) thru (G), automatically calculated. To update, click below

COMMENTS:

7. WATER QUALITY

ANNUAL NITRATE SAMPLING

Regulations require a minimum of annual sampling for nitrate. If any nitrate result is >= 1/2 the MCL of 45 mg/l (i.e., a result of >= 23 mg/l
nitrate) then quarterly monitoring must be initiated.

Did your system conduct monitoring for nitrate during 2013 from each source?

--Pick one-- Yes No Not Applicable (i.e., 100% purchased water)

NOTE: If there were any sources that were not monitored because they were offline during 2013, you must
contact your local regulatory agency to avoid an enforcement action for failure to monitor.

BACTERIOLOGICAL SAMPLE SITING PLAN

The coliform monitoring regulations require that an updated sample-siting plan be submitted at least every 10 years, and at any time the plan
no longer ensures representative monitoring of the system (Section 64422 of Title 22).

Date of current bacteriological sample siting plan:

COMMENTS:

8. WATER TREATMENT

Treatment Plant Name "NONE" if no plants in SDWIS	Treatment Plant Classification
		1 - 4 of 4

If treatment was added or changed in any way in 2013, provide a brief description and identify the water source

DIRECT ADDITIVES

Are all chemicals used NSF/ANSI Standard 60 certified?

--Pick one-- Yes No Not sure N/A (no chemicals used)

INDIRECT ADDITIVES

As of March 9, 2008, a water system shall not use any chemical, material, lubricant, or product in the production, treatment or distribution of
drinking water that comes in contact with the drinking water that does not have certification of meeting NSF/ANSI standard 61.

Does your water system have procedures to ensure all future equipment and materials meet this standard?

--Pick one-- Yes No

If you have any questions on the requirements related to indirect additives, you may contact your local regulatory agency.

COMMENTS:

9. CROSS-CONNECTION CONTROL

	Total Number in System	Number Installed in 2013	Number Tested in 2013	Number Failed in 2013	Number Repaired/ Replaced
Backflow Assemblies on the Service Connections or Meter
Backflow Assemblies On-site but not on the Service Connections or Meter
Air-gap Separation

No. of Inactive Backflow Prevention Assemblies in water system in 2013 :
Date of last cross-connection control survey done on the system:
Name of designated Cross Connection Control Program Coordinator:

Describe any cross-connection incidents that occurred during 2013:

COMMENTS:

10. CONSUMER CONFIDENCE REPORT (does not apply to Transient Noncommunity water systems)

THE 2013 CCR MUST BE DISTRIBUTED TO YOUR CUSTOMERS AND A COPY SUBMITTED TO YOUR LOCAL REGULATORY AGENCY BY JULY 1, 2014.

CERTIFICATION MUST BE SUBMITTED TO YOUR LOCAL REGULATORY AGENCY BY OCTOBER 1, 2014, STATING THAT THE 2013 CCR HAS BEEN DISTRIBUTED
TO CUSTOMERS AND THAT THE INFORMATION IS CORRECT.

The CCR guidance, CCR template, and the certification form can be obtained from the CDPH web site
at:http://www.cdph.ca.gov/certlic/drinkingwater/Pages/CCR.aspx

Indicate the date your 2013 CCR was distributed or will be distributed to your customers:

mm/dd/yyyy

COMMENTS:

11. OPERATOR CERTIFICATION

A. Please list the State certified Water Treatment Plant Operators employed by your water system that supervise and direct the operation
of your water treatment plants, beginning with the chief operator(s) .

Your Highest Treatment System Classification is:  

Name	Grade of Operator	Chief or Shift1 (C/S)	Operator Number	Expiration Date
					1 - 4 of 4

¹Use “C” for Chief Operator and “S” for Shift Operator. If neither, leave blank.

Do your Chief and Shift Treatment Plant Operators have the minimum level required? --Pick one-- Yes No Don't Know

B. Please list the State certified Water Distribution Operators employed by your water system that supervise and direct the operation
of your distribution systems, beginning with the chief operator(s) .

Your Distribution System Classification is:  

Name	Grade of Operator	Chief or Shift1 (C/S)	Operator Number	Expiration Date
					1 - 4 of 4

¹Use “C” for Chief Operator and “S” for Shift Operator. If neither, leave blank.

Do your Chief and Shift Distribution System Operators have the minimum level required? --Pick one-- Yes No Don't Know

COMMENTS:

12. WATER SYSTEM IMPROVEMENTS

The California Waterworks Standards (Section 64556) require an amended permit for any of the following improvements or modifications:

• Addition of a new distribution reservoir with a capacity of 100,000 gallons or more
• Modification or extension of the existing distribution system using an alternative to the requirements of the California Waterworks Standards
  (see Sections 64570 through 64578)
• Modification of the water supply by:
  • Adding a new source
  • Changing the status of an existing source (for example, active to standby) or
  • Changing or altering a source, such that the quality or quantity of water supply could be affected
• Any addition or change in treatment, including
  • Design capacity
  • Process
• Expansion of the existing service area by 20 percent or more of the number of service connections specified in your current permit.

If your water system made any improvements or modifications during 2013 for which a permit was not obtained, please describe the improvements
or modifications below.

Indicate any planned improvements or modifications for 2014.

COMMENTS:

13. COMPLAINTS REPORTED (WRITTEN OR VERBAL)

Type of Complaint	No. of Complaints Reported by Customers	No. of Complaints Investigated	No. of Complaints reported to CDPH	Brief Description of Cause and Corrective Action taken
Taste and Odor
Color
Turbidity
Visible Organisms
Pressure (High or Low)
Water Outages
Illnesses (Waterborne)
Other (Specify)
Total No. of Complaints*

*Calculated field

COMMENTS:

14. SYSTEM PROBLEMS

Type of Problem	No. of Problems	No. of Problems Investigated	No. of Problems Reported to CDPH	Brief Description of Cause and Corrective Action Taken
Service Connection Breaks/ Leaks
Main Breaks/Leaks
Water Outages
Boil Water Orders
Total*

COMMENTS:

15. ONGOING WATER SYSTEM VIOLATIONS

Is your water system operating under a continuous violation?

--Pick one-- Yes No

If yes, respond to the following:

Type of violation (for example, specify “Nitrate MCL” violation if your wells exceeds the nitrate MCL of 45 mg/L
Dates in 2013 that public notification was provided to users
Corrective action taken in 2013
Was bottled water provided to users?	--Pick one-- Yes No
If yes, how was bottled water provided, for example, direct delivery?
Describe anticipated schedule to return to compliance

COMMENTS:

16. WATER CONSERVATION AND DROUGHT PREPAREDNESS

Date of your revised Drought Preparedness Plan, if any:
If you experienced water shortages in 2013, please estimate the amount of shortfall in millions of gallons:
Did drought conditions cause you to activate emergency standby wells in 2013?	--Pick one-- Yes No
Do you project water shortages in the current calendar year?	--Pick one-- Yes No
Did you implement NEW water conservation measures in 2013?	--Pick one-- Yes No
If you implemented NEW water conservation measures in 2013, please estimate how much water was conserved in millions of gallons:       (MG)       % reduction in demand
Do you anticipate having to go to mandatory rationing in the upcoming year?	--Pick one-- Yes No
Are your water sources metered?	--Pick one-- Yes No
Do you routinely monitor the static water levels in your wells?	--Pick one-- Yes No
Do you routinely monitor the pumping water levels in your wells?	--Pick one-- Yes No
Are these levels recovering, declining or steady?:	--Pick one-- Recovering Declining Steady

Please list any other long term actions you are considering or planning:

COMMENTS:

Disclosure: Be advised that Section 116725 and 116730 of the California Health and Safety Code
states that any person who knowingly makes any false statement on any report or document
submitted for the purpose of compliance may be liable for a civil penalty not to exceed
five thousand dollars ($5,000) for each separate violations for each day that the violation
continues. In addition, the violators may be prosecuted in criminal court and upon conviction, be
punished by a fine of not more than $25,000 for each day of violation, or be imprisoned in county jail
not to exceed one year, or both the fine and imprisonment.