LARGE WATER SYSTEM
2017 ANNUAL REPORT TO THE DRINKING WATER PROGRAM
FOR YEAR ENDING DECEMBER 31, 2017
[Section 116530 Health & Safety Code]

WATER SYSTEM INFORMATION
Water System No.:
Water System Name:
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) Note: NO P.O. Box	Zip must be 99999 or 99999-9999
General Office Phone: (with area code)	This must be a phone number (999) 999-9999
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

ONLY FOR COMMUNITY WATER SYSTEMS

Your water system classification is:  

If you have questions about completing this section of the report, please contact the Program Liaison Unit at DDW-PLU@waterboards.ca.gov or call (916) 449-5158.

CERTIFICATION FOR REDUCTION OF ANNUAL FEES FOR PUBLIC WATER SYSTEMS SERVING DISADVANTAGED COMMUNITY (DAC)

I certify under penalty of perjury under the laws of the State of California as a duly authorized representative of the public water system for which this document is being submitted that the foregoing is true and correct: the public water system for which this report is being submitted served a disadvantaged community (as defined in Title 22, Division 4, Chapter 14.5, section 64300 of the California Code of Regulations) for the year in which this report is applicable, and, if requested to do so by the State Board, will provide documentation to the State Board upon request, which may include an income survey, that the public water system served a disadvantaged community during the time period for which this report applies.

If you checked the box above you are required to submit a written, signed certification with this 2017 EAR that the public water system serves a disadvantaged community. If this is a new request to be deemed a disadvantaged community, additional documentation is required demonstrating the income status of the community. Please follow this LINK for additional information on how to submit the annual certification or a new request.

To upload DAC Certificate, click "Upload DAC" link below.
Upload DAC

REPORT SUBMITTED BY:
Note: Your name and title, email address, and work phone number are disclosable report information that may be obtained through the Public Records Act.
Name:
Title:
Work 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.

IMPORTANT: Each water system must have one and only one Administrative Contact AND one and only one Financial Contact. The same person may be both the Administrative and Financial Contacts.

Please provide an email address for the Administrative Contact as most email communication, particularly email blasts, from the Division of Drinking Water will be sent to the email address of the Administrative Contact.
PHONE TYPE: Home – if you use your home or personal phone number as your business number, use the HOME phone type instead and leave the BUSINESS phone type blank.
Only the BUSINESS phone type will appear in Drinking Water Watch (https://sdwis.waterboards.ca.gov/PDWW/), which can be viewed by the public, if the General Office phone number is not provided (see Water System Information section under the Intro tab).

NAME, TITLE & ADDRESS			PHONE TYPE	PHONE NO.	EMAIL	CONTACT TYPE (pick all that apply)
			Business Home	This must be a phone number (999) 999-9999 This must be a phone number (999) 999-9999	This must be an email address This must be an email address	** Delete Contact ** Administrative	Operator
			Facsimile	This must be a phone number (999) 999-9999		Financial	Emergency
			Mobile	This must be a phone number (999) 999-9999		Designated Operator In Charge	Water Quality
Zip must be 99999 or 99999-9999			Emergency	This must be a phone number (999) 999-9999		Owner	Legal
						Funding	Contract Operator
			Business Home	This must be a phone number (999) 999-9999 This must be a phone number (999) 999-9999	This must be an email address This must be an email address	** Delete Contact ** Administrative	Operator
			Facsimile	This must be a phone number (999) 999-9999		Financial	Emergency
			Mobile	This must be a phone number (999) 999-9999		Designated Operator In Charge	Water Quality
Zip must be 99999 or 99999-9999			Emergency	This must be a phone number (999) 999-9999		Owner	Legal
						Funding	Contract Operator
			Business Home	This must be a phone number (999) 999-9999 This must be a phone number (999) 999-9999	This must be an email address This must be an email address	** Delete Contact ** Administrative	Operator
			Facsimile	This must be a phone number (999) 999-9999		Financial	Emergency
			Mobile	This must be a phone number (999) 999-9999		Designated Operator In Charge	Water Quality
Zip must be 99999 or 99999-9999			Emergency	This must be a phone number (999) 999-9999		Owner	Legal
						Funding	Contract Operator
			Business Home	This must be a phone number (999) 999-9999 This must be a phone number (999) 999-9999	This must be an email address This must be an email address	** Delete Contact ** Administrative	Operator
			Facsimile	This must be a phone number (999) 999-9999		Financial	Emergency
			Mobile	This must be a phone number (999) 999-9999		Designated Operator In Charge	Water Quality
Zip must be 99999 or 99999-9999			Emergency	This must be a phone number (999) 999-9999		Owner	Legal
						Funding	Contract Operator
			Business Home	This must be a phone number (999) 999-9999 This must be a phone number (999) 999-9999	This must be an email address This must be an email address	** Delete Contact ** Administrative	Operator
			Facsimile	This must be a phone number (999) 999-9999		Financial	Emergency
			Mobile	This must be a phone number (999) 999-9999		Designated Operator In Charge	Water Quality
Zip must be 99999 or 99999-9999			Emergency	This must be a phone number (999) 999-9999		Owner	Legal
						Funding	Contract Operator
			Business Home	This must be a phone number (999) 999-9999 This must be a phone number (999) 999-9999	This must be an email address This must be an email address	** Delete Contact ** Administrative	Operator
			Facsimile	This must be a phone number (999) 999-9999		Financial	Emergency
			Mobile	This must be a phone number (999) 999-9999		Designated Operator In Charge	Water Quality
Zip must be 99999 or 99999-9999			Emergency	This must be a phone number (999) 999-9999		Owner	Legal
						Funding	Contract Operator
			Business Home	This must be a phone number (999) 999-9999 This must be a phone number (999) 999-9999	This must be an email address This must be an email address	** Delete Contact ** Administrative	Operator
			Facsimile	This must be a phone number (999) 999-9999		Financial	Emergency
			Mobile	This must be a phone number (999) 999-9999		Designated Operator In Charge	Water Quality
Zip must be 99999 or 99999-9999			Emergency	This must be a phone number (999) 999-9999		Owner	Legal
						Funding	Contract Operator
			Business Home	This must be a phone number (999) 999-9999 This must be a phone number (999) 999-9999	This must be an email address This must be an email address	** Delete Contact ** Administrative	Operator
			Facsimile	This must be a phone number (999) 999-9999		Financial	Emergency
			Mobile	This must be a phone number (999) 999-9999		Designated Operator In Charge	Water Quality
Zip must be 99999 or 99999-9999			Emergency	This must be a phone number (999) 999-9999		Owner	Legal
						Funding	Contract Operator
Add Additional Contact						(pick all that apply)
			Business	This must be a phone number (999) 999-9999	This must be an email address This must be an email address	Administrative	Operator
			Home	This must be a phone number (999) 999-9999		Financial	Emergency
			Facsimile Mobile	This must be a phone number (999) 999-9999 This must be a phone number (999) 999-9999		Designated Operator In Charge	Water Quality
Zip must be 99999 or 99999-9999			Emergency	This must be a phone number (999) 999-9999		Owner	Legal
						Funding	Contract Operator
Add Additional Contact						(pick all that apply)
			Business	This must be a phone number (999) 999-9999	This must be an email address This must be an email address	Administrative	Operator
			Home	This must be a phone number (999) 999-9999		Financial	Emergency
			Facsimile Mobile	This must be a phone number (999) 999-9999 This must be a phone number (999) 999-9999		Designated Operator In Charge	Water Quality
Zip must be 99999 or 99999-9999			Emergency	This must be a phone number (999) 999-9999		Owner	Legal
						Funding	Contract Operator
Add Additional Contact						(pick all that apply)
			Business	This must be a phone number (999) 999-9999	This must be an email address This must be an email address	Administrative	Operator
			Home	This must be a phone number (999) 999-9999		Financial	Emergency
			Facsimile Mobile	This must be a phone number (999) 999-9999 This must be a phone number (999) 999-9999		Designated Operator In Charge	Water Quality
Zip must be 99999 or 99999-9999			Emergency	This must be a phone number (999) 999-9999		Owner	Legal
						Funding	Contract Operator
Add Additional Contact						(pick all that apply)
			Business	This must be a phone number (999) 999-9999	This must be an email address This must be an email address	Administrative	Operator
			Home	This must be a phone number (999) 999-9999		Financial	Emergency
			Facsimile Mobile	This must be a phone number (999) 999-9999 This must be a phone number (999) 999-9999		Designated Operator In Charge	Water Quality
Zip must be 99999 or 99999-9999			Emergency	This must be a phone number (999) 999-9999		Owner	Legal
						Funding	Contract Operator

COMMENTS:

2. POPULATION SERVED

Permanent population or number of long-term residents*: Please follow this LINK for instructions to determine population.

This must be a whole number without commas

*Long-term resident means someone who resides within the water system service area for more than half of the year.

Method used to determine population:

--- Pick One --- Water service area matches municipal area "Persons per residential connection” population method Other

If permanent population is based on "Other" , identify the methods or sources of how it was estimated::

Seasonal Maximum Population (If applicable):

This must be a whole number without commas

Provide season :

Begin Date		End Date
MM	DD	MM	DD
Month must be between 1 and 12This must be a 2 digit month	Day must be between 1 and 31This must be a 2 digit day	Month must be between 1 and 12This must be a 2 digit month	Day must be between 1 and 31This must be a 2 digit day

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, 2017)

A. Active Service Connections:

Total Active Potable Water Connections currently in Division of Drinking Water database:

The total number of Service Connections as of December 31, 2017 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 and fire hydrants. These connections are not counted toward “service connections” for compliance purposes.	Unmetered	Metered	Total*	Unmetered	Metered	Total*
Single-family Residential: single family detached dwellings	This must be a whole number without commas	This must be a whole number without commas		This must be a whole number without commas	This must be a whole number without commas
Multi-family Residential: Apartments, condominiums, town houses, duplexes and trailer parks	This must be a whole number without commas	This must be a whole number without commas		This must be a whole number without commas	This must be a whole number without commas
Commercial/Institutional: Retail establishments, office buildings, laundries, schools, prisons, hospitals, dormitories, nursing homes, hotels	This must be a whole number without commas	This must be a whole number without commas		This must be a whole number without commas	This must be a whole number without commas
Industrial: All manufacturing	This must be a whole number without commas	This must be a whole number without commas		This must be a whole number without commas	This must be a whole number without commas
Landscape Irrigation: Parks, play fields, cemeteries, median strips, golf courses	This must be a whole number without commas	This must be a whole number without commas		This must be a whole number without commas	This must be a whole number without commas
Agricultural Irrigation: Irrigation of commercially-grown crops	This must be a whole number without commas	This must be a whole number without commas		This must be a whole number without commas	This must be a whole number without commas
Total Active Connections*

*Calculated field

	Potable Water			Recycled Water
TYPE	Unmetered	Metered	Total*	Unmetered	Metered	Total*
Other: Fire suppression, street cleaning, line flushing, construction meters, temporary meters	This must be a whole number without commas	This must be a whole number without commas		This must be a whole number without commas	This must be a whole number without commas

B. Number of Inactive Connections (all types) Include only service connections that have been physically disconnected (i.e., meter removed) from the water system. All other service connections should be considered as “Active.”

This must be a whole number without commas

C. Number of NON-residential customers required to have dedicated outdoor irrigation meters (excluding agricultural connections)

This must be a whole number without commas

COMMENTS:

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

Type	Total No. Approved (by permit)	Total No. New/ Added in 2017	Total No. Inactivated in 2017	Total No. Destroyed in 2017
Active Groundwater Intakes (Wells)	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Active Surface Water Intakes (Raw)	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Active Purchased Water (GW) Connections	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Active Purchased Water (SW) Connections	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Standby Sources1	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Emergency Interconnections	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Inactive Sources2	This must be a whole number without commas		This must be a whole number without commas	This must be a whole number without commas

Are your water sources metered?

--Pick one-- Yes No

¹If a standby source was used in 2017, provide the following information.

Name of the Standby Source used in 2017:	No. of days the Standby Source was in operation:	Were customers notified? (Y/N)	Was the Division of Drinking Water notified? (Y/N)	Describe the reason the Standby Source was used:
					1 - 4 of 4

²Inactive sources are not approved as sources of supply and must be physically disconnected or otherwise isolated so that only an intentional act
by an operator can place the source in service.

COMMENTS:

5. WATER PRODUCED, PURCHASED AND SOLD

The Maximum Day is the day during 2017 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.

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		This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
January		This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas	This must be a number without commas
February		This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas	This must be a number without commas
March		This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas	This must be a number without commas
April		This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas	This must be a number without commas
May		This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas	This must be a number without commas
June		This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas	This must be a number without commas
July		This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas	This must be a number without commas
August		This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas	This must be a number without commas
September		This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas	This must be a number without commas
October		This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas	This must be a number without commas
November		This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas	This must be a number without commas
December		This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas	This must be a number without commas
Annual Total*
Percent Treated4		This must be a number without commas

PWS = Public Water System

^*Calculated field

Non-potable = water supplies, except recycled water, that do not enter the drinking water distribution system and are for non-potable uses only such as irrigation

Recycled = domestic wastewater which as a result of treatment is suitable for uses other than potable use 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. Total water production includes water that is sold to another water system. 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 and fluoridation.

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

If you have questions about completing this section of the report, please contact Kathy.Frevert@Waterboards.ca.gov or call (916) 322-5274.

Residential Water Rates

Indicate the type of residential 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 Allocation Based Other Rate Structure (specify your rate structure in the box for comments) We Do Not Charge A Water Rate (explain below)

If your water system doesn’t have rates, explain why: --Pick one-- Supplier is educational facility with its own water source Supplier is Institution with its own water source Supplier is business with its own water source Supplier is park or recreational facility with its own water source Other (explain in comment box below))

Comments on rate structure:

What is your billing frequency?	--Pick one-- monthly bi-monthly quarterly annually other
If tiered, what is the number of tiers?	--Pick one-- Not Tiered 2 3 4 5 6 7
Units of Measure (UOM) for this table:	--Pick one-- Gallons (Gal) Hundred Cubic Feet Thousand Gallons Million Gallons Acre Feet

Residential Water Rates	Single-family		Multi-family
	Upper level of water volume for each Tier in UOM provided	Cost per Unit	Upper level of water volume for each Tier in UOM provided	Cost per Unit
Flat Base Rate
Tier Rate Structure level 1
Tier Rate Structure level 2
Tier Rate Structure level 3
Tier Rate Structure level 4
Tier Rate Structure level 5
Tier Rate Structure level 6
Tier Rate Structure level 7
Comments:
Date of most recent update to the rate structure: MM/DD/YYYY	This must be a date (e.g. 12/31/2010)
Describe the changes that were made in the update:
Residential service connections
Select the most common residential meter size:	--Pick one-- 3/4 inch 5/8 inch 1 inch other
a. What is the service connection fee for single-family new construction based on the most common meter size listed above)?	This must be a number without commas
b. What is the connection fee for a single-family existing home based on the most common meter size indicated above?	This must be a number without commas
c. What is the connection fee for multi-family new construction based on the most common meter size indicated above?	This must be a number without commas
d. Include your webpage on residential water rates and service fees, if applicable:
Comments:
Date of most recent update to the new connection fee: MM/DD/YYYY	This must be a date (e.g. 12/31/2010)

Check items included in new residential connection fees:

	Existing infrastructure buy-in (e.g., water treatment/ conveyance/sewage treatment )
	Upgrades to infrastructure (seismic retrofits, pipe replacements, etc.)
	Storm water management system
	Debt service charge
	Development of new water supplies
	Other
Comment:

Select the most common non-residential meter size: --Pick one-- 3/4 inch 5/8 inch 1 inch other

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

Connection Type	FLAT BASE RATE (FBR)	If FBR + UUR, what is the volume allowed before UUR applies	UNIFORM USAGE RATE (UUR)	VARIABLE BASE RATE (provide range) (VBR)		VARIABLE USAGE RATE (provide range) (VUR)
	$ (Base)	HCF	$ per HCF	$ Low	$ High	$ per HCF Low	$ per HCF High
NON-RESIDENTIAL
Commercial/Institutional	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas
Industrial	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas
Landscape Irrigation	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas
Agricultural Irrigation	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas
Other	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas

AFFORDABLE DRINKING WATER

For each amount of water delivered to a single-family residential customer shown below, what is charged (in dollars) to the customer?

For each of the three water volumes shown below, provide what would be the monthly water bill for a single-family residential customer. Enter the monthly Water Charges and Other Charges for each water volume. For example, if a single-family customer used 12 HCF in a month, the total bill would include water charges for using 12 HCF and other charges that are added to the bill. Other charges may include property taxes, fire suppression, waste water, etc., which are determined locally. Click the “Update Totals” button to automatically add the charges together to show a Total Monthly Water Bill that a residential customer would pay when its household used the specified amount of water.

a. 6 HCF
Drinking Water Charges (Fixed and variable water charges)	This must be a number without commas	Dollars/month
Other Charges (e.g., property tax, fire suppression, waste water, other)	This must be a number without commas	Dollars/month
Total Monthly Water Bill (Automatic sum of Water Charges and Other Charges)*		Dollars/month
b. 12 HCF
Drinking Water Charges (Fixed and variable water charges)	This must be a number without commas	Dollars/month
Other Charges (e.g., property tax, fire suppression, waste water, other)	This must be a number without commas	Dollars/month
Total Monthly Water Bill (Automatic sum of Water Charges and Other Charges)*		Dollars/month
c. 24 HCF
Drinking Water Charges (Fixed and variable water charges)	This must be a number without commas	Dollars/month
Other Charges (e.g., property tax, fire suppression, waste water, other)	This must be a number without commas	Dollars/month
Total Monthly Water Bill (Automatic sum of Water Charges and Other Charges)*		Dollars/month

*Calculated field, to update calculated field, click button below

SHUT-OFFS Click the “Update Totals” button to automatically add the Single Family and Multifamily Accounts 1. How many accounts for residential service connections had their water shut off once during the year of 2017 for delinquent payments?
Single-Family Accounts		This must be a whole number without commas
Multi-family Accounts		This must be a whole number without commas
Total*
2. How many accounts for residential service connections had their water shut off more than once during 2017 for delinquent payments?
Single-Family Accounts		This must be a whole number without commas
Multi-family Accounts		This must be a whole number without commas
Total*
3. What is the residential reconnection fee to restore drinking water service due to delinquent payments?
Single-Family Accounts		This must be a whole number without commas
Multi-family Accounts		This must be a whole number without commas
Total*
4. What was the median duration of the shut-offs (in days) for continuously occupied residential service accounts?
Single-Family Accounts		This must be a whole number without commas
Multi-family Accounts		This must be a whole number without commas
Total*
5. If you offer an extended repayment or other customer payment assistance plan, how many continuously occupied residential customer accounts participated?
Single-Family Accounts		This must be a whole number without commas
Multi-family Accounts		This must be a whole number without commas
Total*
How many of the continuously occupied residential accounts were shut off at least once during calendar year 2017 and were enrolled in an extended repayment plan or other customer payment assistance plan at the time of the service disconnection?
Single-Family Accounts		This must be a whole number without commas
Multi-family Accounts		This must be a whole number without commas
Total*

*Calculated field, to update calculated field, click button below

Affordable Drinking Water Assistance
Do you provide lifeline/low income subsidies?	--Pick one-- Yes No
If yes, how is the program funded?
How much funding is allocated to the program annually?	This must be a whole number without commas
If yes, how many residential accounts receive the low-income subsidy?	This must be a whole number without commas
Who is eligible for drinking water assistance? Check those that are eligible:
Disabled
Low Income Families
Seniors
Special Medical Need
Other Please describe:

6b. WATER DELIVERIES

Units of Measure (UOM) 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	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas
February	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas
March	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas
April	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas
May	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas
June	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas
July	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas
August	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas
September	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas
October	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas
November	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas
December	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas	This must be a number without commas		This must be a number without commas	This must be a number without commas
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 (Maximum Contaminant Level) of 10 mg/l as nitrogen (i.e., a result of >= 5 mg/l
as nitrogen) then quarterly monitoring must be initiated.

Did your system conduct monitoring for nitrate during 2017 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 2017,
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:

This must be a date (e.g. 12/31/2010)

DIRECT ADDITIVES

Pursuant to Section 64590, Title 22 of the California Code of Regulations, (effective January 1, 1994), all chemicals or products, including chlorine,
added directly to the drinking water as part of a treatment process must meet the ANSI/NSF Standard 60. Please complete the following table
for each chemical used by this water system. If you are not sure whether a chemical you are using meets this standard, contact the manufacturer
or distributor of the chemical.

If you do not use any direct additives, put “NONE” in each column of the first row.

Name of Chemical	Name of Manufacturer	Purpose of using chemical	Chemical is ANSI/NSF Standard 60 certified (Y/N)	Use initiated in 2017 (Y/N)
					1 - 4 of 4

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:

8. CROSS-CONNECTION CONTROL

	Total Number in System	Number Installed in 2017	Number Tested in 2017	Number Failed in 2017	Number Repaired/ Replaced
Backflow Assemblies on the Service Connections or Meter (Reduced Pressure Principle and Double Check Valve assemblies)	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Backflow Assemblies On- site but not on the Service Connections or Meter (Reduced Pressure Principle and Double Check Valve assemblies)	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Air-gap Separation	This must be a whole number without commas	This must be a whole number without commas

No. of Inactive Backflow Prevention Assemblies in water system in 2017 :			This must be a whole number without commas
Date of last cross-connection control survey done on the system: If ongoing, enter the last day of the year, e.g., 12/31/2017			This must be a date (e.g. 12/31/2010)
Cross Connection Control Program Coordinator
Name:
Certification Number:
Business Phone:	This must be a phone number (999) 999-9999	Email Address:	This must be an email address
Certification or training received:

Describe any cross-connection incidents that occurred during 2017:

COMMENTS:

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

THE 2017 CCR MUST BE DISTRIBUTED TO YOUR CUSTOMERS AND A COPY SUBMITTED TO YOUR LOCAL REGULATORY AGENCY BY JULY 1, 2018. IN ADDITION, PUBLIC WATER SYSTEMS THAT ARE ALSO REGULATED BY THE CALIFORNIA PUBLIC UTILITIES COMMISSION (PUC) MUST MAIL A COPY OF THEIR CCR TO THE PUC BY JULY 1, 2018.

CERTIFICATION MUST BE SUBMITTED TO YOUR LOCAL REGULATORY AGENCY BY OCTOBER 1, 2018, STATING THAT THE 2017 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 Division of Drinking Water web site
at:http://www.waterboards.ca.gov/drinking_water/certlic/drinkingwater/CCR.shtml

Indicate the date your 2017 CCR was distributed or will be distributed to your customers:

This must be a date (e.g. 12/31/2010) mm/dd/yyyy

PUBLIC WATER SYSTEMS THAT SERVE 100,000 OR MORE PERSONS ARE REQUIRED TO POST THEIR CCR ON THE INTERNET.

If your water system serves 100,000 or more persons, indicate the date the CCR was or will be posted to the Internet:

This must be a date (e.g. 12/31/2010)

If applicable, please provide the URL link to the CCR posted on the Internet:

COMMENTS:

10. 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:  

Check this box if your public water system has designated a Chief Treatment Operator.

Name of Chief Treatment Operator (First name Last name):
Grade of Chief Treatment Operator (1, 2, 3, 4 or 5):	This must be a whole number without commas
Treatment Operator Number (4 or 5 digits):	This must be a whole number without commas
Treatment Certification Expiration Date (MM/DD/YYYY):	This must be a date (e.g. 12/31/2010)

Treatment Operator Name (First name Last name)	Grade of Treatment Operator (1, 2, 3, 4, or 5)	Chief or Shift1 (C, S or X)	Treatment Operator Number (4 or 5 digits)	Treatment Certification Expiration Date (MM/DD/YYYY)
					1 - 4 of 4

¹Use “C” for Chief Operator and “S” for Shift Operator. If neither, put an "X". Do not leave blank.

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

B. Please list the State certified Water Distribution System 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:  

Check this box if your public water system has designated a Chief Distribution Operator.

Name of Chief Distribution Operator (First name Last name):
Grade of Chief Distribution Operator (1, 2, 3, 4 or 5):	This must be a whole number without commas
Distribution Operator Number (4 or 5 digits):	This must be a whole number without commas
Distribution Certification Expiration Date (MM/DD/YYYY):	This must be a date (e.g. 12/31/2010)

Distribution Operator Name (First name Last name)	Grade of Distribution Operator (1, 2, 3, 4, or 5)	Chief or Shift1 (C, S or X)	Distribution Operator Number (4 or 5 digits)	Distribution Certification Expiration Date (MM/DD/YYYY)
					1 - 4 of 4

¹Use “C” for Chief Operator and “S” for Shift Operator. If neither, put an "X". Do not leave blank.

Do your Chief and Shift Distribution System Operators have the minimum level required? --Pick one-- Yes No Don't Know Not Applicable (transient non-community water system)

COMMENTS:

11. 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 2017 for which a permit was not obtained, please describe
the improvements or modifications below.

Indicate any planned improvements or modifications for 2018.

COMMENTS:

12. COMPLAINTS REPORTED (WRITTEN OR VERBAL)

Type of Complaint	No. of Complaints Reported by Customers	No. of Complaints Investigated	No. of Complaints reported to the Division of Drinking Water or Local County Staff	Brief Description of Cause and Corrective Action taken
Taste and Odor	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Color	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Turbidity	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Visible Organisms	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Pressure (High or Low)	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Water Outages1	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Illnesses (Waterborne)	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Other (Specify)	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Total No. of Complaints*

¹These are customer complaints of a water outage and not necessarily the same as the water outages reported under “System Problems” in the Distribution Section of the EARDWP.
*Calculated field

COMMENTS:

13. RECYCLED WATER USE

Do you have recycled water in your service area (provided by you or another utility)?

--Pick one-- Yes No Don't Know

Recycled Water (RW) Use Sites	Total No. of Approved Sites as of Dec. 31, 2017	No. of New Sites Approved in 2017	No. of Sites Proposed for 2018
Irrigation, Agriculture	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Irrigation, Landscape	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Industrial	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Dual-plumbed (In-building)	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Dual-plumbed (Single-family lot)	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Cooling Towers	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Other	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Total*

Name of the recycled water coordinator:
Business Phone:	This must be a phone number (999) 999-9999
Email address:	This must be an email address
How many inspections of recycled water use sites were conducted in 2017?	This must be a whole number without commas
How many pressure/shutdown tests were performed in 2017?	This must be a whole number without commas
Do all of your recycled water uses sites have an on-site supervisor?	--Pick one-- Yes No
How many recycled water uses sites do not have an on-site supervisor?	This must be a whole number without commas

COMMENTS:

14. SYSTEM OPERATION - TREATMENT

A. GROUNDWATER TREATMENT (respond only if groundwater treatment is provided)

Groundwater Treatment Plant Name	Treatment Plant Classification	Capacity (MGD)	Type of Treatment	Date of Operations Plan	Is Operations Plan Current? (Y/N)
						1 - 6 of 6

Describe any plant problems, process failures, major shutdowns, etc., which occurred in 2017 and substantially affected the plant performance AND/OR
any significant modifications or maintenance provided to the plant(s):

B. SURFACE WATER TREATMENT (respond only if surface water treatment is provided)

Surface water Treatment Plant Name	Treatment Plant Classification	Capacity (MGD)	Type of Treatment	Date of Operations Plan	Is Operations Plan Current? (Y/N)
						1 - 6 of 6

Describe any plant problems, process failures, major shutdowns, etc., which occurred in 2017 and substantially affected the plant performance AND/OR
any significant modifications or maintenance provided to the plant(s):

TD = Treatment or Distribution operator at any level

NR, N/A, NA = There are no facilities subject to the Certified Treatment Plant Operator requirements

Date of current Emergency Disinfection Plan (EDP)*:	This must be a date (e.g. 12/31/2010)
*As required under Section 64660(c)(2). The EDP may be included in your water system’s Emergency Response Plan or Operations Plan. If so, provide the Name and Date of those plans below:.
Name of Document that includes the Emergency Disinfection Plan:
Date of document that includes the Emergency Disinfection Plan:	This must be a date (e.g. 12/31/2010)
Date of last watershed sanitary survey report :	This must be a date (e.g. 12/31/2010)
Date planned to complete next watershed sanitary survey report*:	This must be a date (e.g. 12/31/2010)
*As required under Section 64665, each watershed sanitary survey shall be updated at least every 5 years.

COMMENTS:

15. SYSTEM OPERATION – DISTRIBUTION

A1. DEAD-END FLUSHING PROGRAM

Total No. in System	No. with Blowoffs	No. Flushed in 2017	Frequency of Flushing
This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas

A2. ALL FLUSHING OPERATIONS

Units of Measure for total volume reported below:	--Pick one-- Gallons Million Gallons Acre-feet (AF) 100 cubic feet
Total Volume in units of measure selected above; include all types of flushing, not just dead-end flushing:	This must be a number without commas

B. VALVE EXERCISE PROGRAM

Size Range of Valves	Total No. in System	No. Exercised in 2017	Frequency of Valve Exercising
	This must be a whole number without commas	This must be a whole number without commas

C. STORAGE TANK/RESERVOIR INSPECTION/CLEANING PROGRAM

(Do not include pressure tanks)

Tank name	Capacity (in million gallons, MG)	Year installed	Date of last inspection	Date of last cleaning	Date re-lined or coated
						1 - 6 of 6

D. SYSTEM PROBLEMS

Type of Problem	No. of Problems	No. of Problems Investigated	No. of Problems Reported to the Division of Drinking Water or Local County Staff	Brief Description of Cause and Corrective Action Taken
Service Connection Breaks/ Leaks	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Main Breaks/Leaks	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Water Outages	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Boil Water Orders	This must be a whole number without commas	This must be a whole number without commas	This must be a whole number without commas
Total*

SECTION E AND F BELOW ARE ONLY FOR RETAIL COMMUNITY WATER SYSTEMS WITH >3,000 SERVICE CONNECTIONS OR SUPPLY >3,000 AF/YEAR

If you have questions about completing this section of the report, please contact Kartiki.Naik@waterboards.ca.gov or call (916) 319-9468.

The information in the section below will be used to help develop water loss performance standards for urban retail water suppliers, as required by SB 555 (2015).

E. INFRASTRUCTURE AND PRESSURE MANAGEMENT

Pipe Material in Distribution System

1. Which materials does your distribution system pipe consist of? Please check all that apply:

Plastic
Steel
Cast Iron
Galvanized Iron
Cement Concrete
Asbestos Cement
Clay
Wood

Pipeline Material	Percentage of distribution pipe system composed of the materials selected above	Average Age (in years)
Plastic	Number must be between 0.00 and 100.0This must be a number without commas	This must be a number without commas
Steel	Number must be between 0.00 and 100.0This must be a number without commas	This must be a number without commas
Cast Iron	Number must be between 0.00 and 100.0This must be a number without commas	This must be a number without commas
Galvanized Iron	Number must be between 0.00 and 100.0This must be a number without commas	This must be a number without commas
Cement Concrete	Number must be between 0.00 and 100.0This must be a number without commas	This must be a number without commas
Asbestos Cement	Number must be between 0.00 and 100.0This must be a number without commas	This must be a number without commas
Clay	Number must be between 0.00 and 100.0This must be a number without commas	This must be a number without commas
Wood	Number must be between 0.00 and 100.0This must be a number without commas	This must be a number without commas
If other, specify below:	Number must be between 0.00 and 100.0This must be a number without commas	This must be a number without commas

2. Percentage of distribution system composed of pipes with a nominal diameter larger than 18 inches Number must be between 0.00 and 100.0This must be a number without commas %

Pressure Management

1. Has your system used Pressure Managed Areas over the past 3 years for the purpose of real loss reduction?

If yes, please check the box.

If not, proceed to question 3. Comments can be provided in question 3.

a) For what percentage of your distribution pipe system were these pressure managed areas established?	Number must be between 0.00 and 100.0This must be a number without commas %
b) What was the average pressure reduction over these pressure managed areas?	Number must be between 0.00 and 999.99This must be a number without commas psi
c) What was the expenditure in establishing and operating these pressure managed areas for your distribution system? (Amount in $)	This must be a number without commas

2. Did you measure the real loss reduction achieved through pressure management?

If yes, please check the box.

If not, proceed to question 4. Comments can be provided in question 3.

a) Specify the average annual real loss reduction achieved over the past 3 years due to these pressure managed areas	This must be a number without commas
b) Specify the Unit of Measure for the average annual real loss reduction reported in Question 2a)	--Pick one-- Gallons Million Gallons Acre-feet(AF) 100 cubic feet

3. Comments on pressure managed areas in your system:

4. Specify the minimum operating pressure, averaged across your distribution system, required to maintain minimum pressure requirements at critical pressure points in your distribution system as per the California Waterworks Standards (California Code of Regulations, Title 22, Division 4, Chapter 16, Article 8, §64602). Number must be between 0.00 and 999.99This must be a number without commas psi

5. Comments on the minimum operating pressure in Question 4

F. REAL LOSS REDUCTION MEASURES

1. Has your system implemented real loss reduction measures (excluding pressure reduction) in 3 years?

If yes, please check the box and proceed to a)

If not, skip questions (a) through (c) below.

a) If yes, please specify the total real loss reduction achieved over the past 3 years using the real loss reduction measures considered above.	This must be a number without commas
b) Specify the Unit of Measure for the average annual real loss reduction reported in Question 1a)	--Pick one-- Gallons Million Gallons Acre-feet(AF) 100 cubic feet
c) What was the expenditure in implementing the above real loss reduction measures for your distribution system? (Amount in $)	This must be a number without commas

2. Comments on real loss reduction measures employed

COMMENTS:

16. EMERGENCY PREPAREDNESS AND RESPONSE

A. EMERGENCY RESPONSE PLANS

PUBLIC WATER SYSTEMS WITH AT LEAST 3,300 OR MORE PERSONS ARE REQUIRED TO REVIEW AND REVISE THEIR EMERGENCY
RESPONSE PLAN TO ENSURE THAT THE PLANS ARE SUFFICIENT TO ADDRESS POSSIBLE DISASTER SCENARIOS.

Do you have an Emergency Response Plan (ERP) that addresses the procedures for the restoration of water service for your water system?	--Pick one-- Yes No
Date of your current Emergency Response Plan:	This must be a date (e.g. 12/31/2010)
Date ERP was last exercised with a tabletop or other activity:	This must be a date (e.g. 12/31/2010)

B. AUXILIARY POWER SUPPLY

Does your water system have backup power for:
1. Sources:	--Pick one-- All Some None Not Applicable
2. Pumping Stations:	--Pick one-- All Some None Not Applicable
3. Water Treatment Plants:	--Pick one-- All Some None Not Applicable
If your system has backup power, how many times per year is it exercised?	This must be a whole number without commas
Can your system maintain system pressure either by backup power or by storage during power outages of 2 hours or less?	--Pick one-- Yes No
Is your backup power system automatic or manual start?:	--Pick one-- Automatic Manual Start Not Applicable

COMMENTS:

17. WATER CONSERVATION AND DROUGHT PREPAREDNESS

Date of your revised Drought Preparedness Plan or Water Shortage Contingency Plan, if any:	This must be a date (e.g. 12/31/2010)
Units of Measure for this section:	--Pick one-- Gallons Million Gallons Acre-feet(AF) 100 cubic feet
If you experienced water shortages in 2017, please estimate the amount of shortfall in units selected for this section:	This must be a number without commas
How many water-shortage response stages are in your drought plan? For “non-applicable”, enter zero.	--Pick one-- 0 1 2 3 4 5 6 7 8+
Did drought conditions cause you to activate emergency standby wells in 2017?	--Pick one-- Yes No Not Applicable (no wells)
Do you project water shortages in the current calendar year?	--Pick one-- Yes No
Did you implement NEW water conservation measures in 2017?	--Pick one-- Yes No
If you implemented NEW water conservation measures in 2017, please estimate how much water was conserved      This must be a number without commas volume of water in units selected for this section      This must be a number without commas % reduction in demand
Do you anticipate having to go to mandatory rationing in the upcoming year?	--Pick one-- Yes No
Do you routinely monitor the static water levels in your wells?	--Pick one-- Yes No Not Applicable (no wells)
Do you routinely monitor the pumping water levels in your wells?	--Pick one-- Yes No Not Applicable (no wells)
Are these levels recovering, declining or steady?:	--Pick one-- Recovering Declining Steady Not Applicable (no wells)

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

What steps have your system taken, if any, to implement current water efficient plumbing standards?

Identify the method your water system uses to discourage excessive water use in support of SB 814 (2016) :	(Check as applicable) Rate structure (e.g., block tiers, water budgets, or rate surcharges above base rates for excessive water use) Excessive water use ordinance, rule, or tariff condition Not implementing Not applicable: not an urban retail water supplier
COMMENTS REGARDING SB 814 :

COMMENTS:

18. CLIMATE CHANGE ADAPTATION AND RESILIENCY FOR WATER UTILITIES

ONLY FOR COMMUNITY WATER SYSTEMS

Your water system classification is:  

If you have questions about completing this section of the report, please contact Joseph.Crisologo@waterboards.ca.gov or call (818) 551-2046.

A. CLIMATE THREATS
What climate-related impacts are of concern for your water system (check all that apply)? Drought Groundwater Depletion Water Quality Degradation Flooding Sea Level Rise Extreme Heat Fire Other None or N/A
B. SENSITIVITY AND MAGNITUDE OF IMPACTS
Qualitatively assess climate change sensitivity of your facilities, and criticality or consequence of disruption. Consider identified climate threats using past experience, and expert judgement based on the magnitude of expected change and extreme events in the future. You do not need numeric answers. USEPA provides a risk assessment tool, called CREAT, to help utilities identify which environmental changes can impact water supply: https://www.epa.gov/crwu/build-resilience-your-utility. More resources are available that may help you complete this section.
Drought | Groundwater Depletion	Decreased water storage (low lake and reservoir levels)	Choose an item --Pick one-- High or Already Experiencing Medium Sensitivity None to Low Sensitivity
	Groundwater depletion (increased extraction, reduced groundwater recharge, etc.)	Choose an item --Pick one-- High or Already Experiencing Medium Sensitivity None to Low Sensitivity
	Change in seasonal runoff and/or loss of snowmelt	Choose an item --Pick one-- High or Already Experiencing Medium Sensitivity None to Low Sensitivity
	Region relies on water diverted from the Delta, imported from the Colorado River, or other climate-sensitive area	Choose an item --Pick one-- High or Already Experiencing Medium Sensitivity None to Low Sensitivity
Water Quality Degradation	Salt-water intrusion into aquifers	Choose an item --Pick one-- High or Already Experiencing Medium Sensitivity None to Low Sensitivity
	Altered water quality during storm events (turbidity shifts, debris flows)	Choose an item --Pick one-- High or Already Experiencing Medium Sensitivity None to Low Sensitivity
	Surface water quality issues related to eutrophication, algal blooms, invasive species	Choose an item --Pick one-- High or Already Experiencing Medium Sensitivity None to Low Sensitivity
Flooding | Sea Level Rise	High flow events and flooding	Choose an item --Pick one-- High or Already Experiencing Medium Sensitivity None to Low Sensitivity
	Inundation due to sea level rise, high tides, and/or coastal storm surges	Choose an item --Pick one-- High or Already Experiencing Medium Sensitivity None to Low Sensitivity
	Aging flood protection infrastructure (levees), or insufficient impoundment capacity	Choose an item --Pick one-- High or Already Experiencing Medium Sensitivity None to Low Sensitivity
Extreme Heat	Peak demand volume surges (due to extreme heat, temperature trends, etc.)	Choose an item --Pick one-- High or Already Experiencing Medium Sensitivity None to Low Sensitivity
	Increases in agricultural water demand or energy sector needs	Choose an item --Pick one-- High or Already Experiencing Medium Sensitivity None to Low Sensitivity
Fire | Other Impacts	Increased fire risk and altered vegetation, e.g., wildfires	Choose an item --Pick one-- High or Already Experiencing Medium Sensitivity None to Low Sensitivity
	Disruption of power supply	Choose an item --Pick one-- High or Already Experiencing Medium Sensitivity None to Low Sensitivity
	Other	Choose an item --Pick one-- High or Already Experiencing Medium Sensitivity None to Low Sensitivity
C. ADAPTATION MEASURES
Identify measures to reduce current vulnerability, or make future modifications based on identified sensitivity of the water system. Indicate status for all projects that your organization has completed, or plan to implement to increase resiliency of the water system to climate change? USEPA’s Adaptation Strategies Guide for Water Utilities provides examples of adaptation: https://www.epa.gov/crwu/learn-how-plan-extreme-weather-events
Install new and deeper drinking water wells, or modify existing wells to increase pumping capacity		Choose an item --Pick one-- Completed In Progress Plan to Implement Will not Implement N/A
Develop local supplemental water supply, enhanced treatment, or increased storage capacity (e.g. recycled water, storm runoff for groundwater recharge, desalination, new reservoir)		Choose an item --Pick one-- Completed In Progress Plan to Implement Will not Implement N/A
Interconnection with other utilities (transfers, mutual aid agreements with neighboring utilities)		Choose an item --Pick one-- Completed In Progress Plan to Implement Will not Implement N/A
Relocate facilities, construct or install redundant facilities		Choose an item --Pick one-- Completed In Progress Plan to Implement Will not Implement N/A
Modify facilities (e.g., install barrier or levee, raise a wall, seal a door, elevate construction)		Choose an item --Pick one-- Completed In Progress Plan to Implement Will not Implement N/A
Conservation measures (demand management, enhanced communication and outreach)		Choose an item --Pick one-- Completed In Progress Plan to Implement Will not Implement N/A
Fire prevention – brush management, partnerships		Choose an item --Pick one-- Completed In Progress Plan to Implement Will not Implement N/A
Alternative or backup energy supply		Choose an item --Pick one-- Completed In Progress Plan to Implement Will not Implement N/A
On-site energy generation		Choose an item --Pick one-- Completed In Progress Plan to Implement Will not Implement N/A
Enhance monitoring program, budget for additional testing and treatment, chemicals		Choose an item --Pick one-- Completed In Progress Plan to Implement Will not Implement N/A
Other		Choose an item --Pick one-- Completed In Progress Plan to Implement Will not Implement N/A

19. LEAD SERVICE LINE REPLACEMENT

ONLY FOR COMMUNITY WATER SYSTEMS

Your water system classification is:  

Section 116885 of the California Health and Safety Code, Lead Service Lines in Public Water Systems, added to the Health and Safety Code by Senate Bill 1398 (2016) and amended by Senate Bill 427 (2017), requires all community water systems (CWS) to compile an inventory of known partial or total lead user service lines in use in its distribution system by July 1, 2018. The inventory must include all user service lines that are active and those that are reasonably expected to become active in the future. Also, Section 116885 requires that CWS identify areas that may have lead user service lines in use, and/or identify any areas within the CWS distribution system that the CWS cannot identify the material that is being used for the service line.

For additional information, please visit https://www.waterboards.ca.gov/drinking_water/certlic/drinkingwater/lead_service_line_inventory_pws.shtml

If you have questions about completing this section of the report, please contact David.Pimentel@Waterboards.ca.gov or call (916) 323-0572.

Date lead service line inventory was completed (MM/DD/YYYY):

This must be a date (e.g. 12/31/2010)

A. User service line inventory:

"User service line" means the pipe, tubing, and fittings connecting a water main to an individual water meter or service connection.

Pipe Material		Estimated Number of Service Lines (Enter “0” if none)	Estimated Total Length of Service Lines (In feet), if applicable
A. Lead		This must be a whole number without commas	This must be a whole number without commas
B. Unknown material		This must be a whole number without commas	This must be a whole number without commas
C. Copper		This must be a whole number without commas
D. Cast iron (ductile pipe)		This must be a whole number without commas
E. Ductile iron		This must be a whole number without commas
F. Galvanized steel		This must be a whole number without commas
G. Polyvinyl chloride (PVC)		This must be a whole number without commas
H. Polyethylene (PE)		This must be a whole number without commas
I. High density polyethylene (HDPE)		This must be a whole number without commas
J. Polybutylene (PB)		This must be a whole number without commas
K. Transite/asbestos cement		This must be a whole number without commas
L. Other materials not listed above:
Identify material 1		This must be a whole number without commas
Identify material 2		This must be a whole number without commas
Identify material 3		This must be a whole number without commas
Identify material 4		This must be a whole number without commas
Total number of service lines inventoried* (calculated field)
Total number of service connections from Section 3 of the EAR		This must be a whole number without commas
Fittings or fittings connecting a water main:
M. Lead fittings NOT on a lead pipe(e.g., goosenecks, pigtails, and corporation stops)		This must be a whole number without commas
N. Lead fittings ON a lead pipe (e.g., goosenecks, pigtails, and corporation stops)		This must be a whole number without commas
O. Fittings of unknown material (e.g., goosenecks, pigtails, and corporation stops)		This must be a whole number without commas
Total number of lead service lines** (calculated field)

*Total number of service lines inventoried (calculated field) = Sum of A through L

**Total number of lead service lines (calculated field) = Sum of A and M

To Update calculated field, click button below

B. Method(s) used to prepare the lead service line inventory in Part A (check all that apply):

Tap Cards or tickets from initial service installation
Plans from water main installation, rehabilitation, and replacement
Records indicating when buildings were constructed
Meter replacement records
Distribution maps, drawings, or GIS
Visual confirmation of pipe material by plumbers or utility crews during maintenance or installation activities
Interviews with water system personnel and/or past employees
Field investigations
Other (describe below):

C. PRINT THIS INVENTORY FORM FOR YOUR SIGNATURE

I certify under penalty of perjury under the laws of the State of California that the foregoing [including any uploaded documents] is true and correct to the best of my knowledge.

Signature:
Name:
Title:
Phone number:	This must be a phone number (999) 999-9999
Date signed (MM/DD/YYYY):	This must be a date (e.g. 12/31/2010)
PWS Name:
PWS No.:

Print this completed form by clicking “Print” below, sign and scan. This is your certified form.
Print

D. UPLOAD SIGNED INVENTORY FORM AND MAP(S) IDENTIFYING AREAS WITH LEAD SERVICE LINES OR SERVICE LINES CONSTRUCTED OF UNKNOWN MATERIAL

Click HERE to upload the certified form if no lead service lines or service lines constructed of unknown material were identified.

OR

Click HERE to upload the maps (only .shp, .kml or .kmz, and .pdf in order of preference) only if you have areas with lead service lines or service lines constructed of unknown material and upload the certified form.

Disclosure: Be advised that Sections 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 purposes of compliance may be liable for a civil penalty not to exceed
five thousand dollars ($5,000) for each separate violation 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 the violation, or be imprisoned in county jail
not to exceed one year, or both the fine and imprisonment.