SMALL 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 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

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, have you previously submitted a written request with documentation for DAC status? If not, please follow this LINK for additional information on how to submit a request. --Pick one-- Yes No Don't Know

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			** Delete Contact ** Administrative	Operator
			Facsimile			Financial	Emergency
			Mobile			Designated Operator In Charge	Water Quality
			Emergency			Owner	Legal
						Funding	Contract Operator
			Business Home			** Delete Contact ** Administrative	Operator
			Facsimile			Financial	Emergency
			Mobile			Designated Operator In Charge	Water Quality
			Emergency			Owner	Legal
						Funding	Contract Operator
			Business Home			** Delete Contact ** Administrative	Operator
			Facsimile			Financial	Emergency
			Mobile			Designated Operator In Charge	Water Quality
			Emergency			Owner	Legal
						Funding	Contract Operator
			Business Home			** Delete Contact ** Administrative	Operator
			Facsimile			Financial	Emergency
			Mobile			Designated Operator In Charge	Water Quality
			Emergency			Owner	Legal
						Funding	Contract Operator
			Business Home			** Delete Contact ** Administrative	Operator
			Facsimile			Financial	Emergency
			Mobile			Designated Operator In Charge	Water Quality
			Emergency			Owner	Legal
						Funding	Contract Operator
			Business Home			** Delete Contact ** Administrative	Operator
			Facsimile			Financial	Emergency
			Mobile			Designated Operator In Charge	Water Quality
			Emergency			Owner	Legal
						Funding	Contract Operator
			Business Home			** Delete Contact ** Administrative	Operator
			Facsimile			Financial	Emergency
			Mobile			Designated Operator In Charge	Water Quality
			Emergency			Owner	Legal
						Funding	Contract Operator
			Business Home			** Delete Contact ** Administrative	Operator
			Facsimile			Financial	Emergency
			Mobile			Designated Operator In Charge	Water Quality
			Emergency			Owner	Legal
						Funding	Contract Operator
Add Additional Contact						(pick all that apply)
			Business			Administrative	Operator
			Home			Financial	Emergency
			Facsimile Mobile			Designated Operator In Charge	Water Quality
			Emergency			Owner	Legal
						Funding	Contract Operator
Add Additional Contact						(pick all that apply)
			Business			Administrative	Operator
			Home			Financial	Emergency
			Facsimile Mobile			Designated Operator In Charge	Water Quality
			Emergency			Owner	Legal
						Funding	Contract Operator
Add Additional Contact						(pick all that apply)
			Business			Administrative	Operator
			Home			Financial	Emergency
			Facsimile Mobile			Designated Operator In Charge	Water Quality
			Emergency			Owner	Legal
						Funding	Contract Operator
Add Additional Contact						(pick all that apply)
			Business			Administrative	Operator
			Home			Financial	Emergency
			Facsimile Mobile			Designated Operator In Charge	Water Quality
			Emergency			Owner	Legal
						Funding	Contract Operator

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, 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
Multi-family Residential: Apartments, condominiums, town houses, duplexes and trailer parks
Commercial/Institutional: Retail establishments, office buildings, laundries, schools, prisons, hospitals, dormitories, nursing homes, hotels
Industrial: All manufacturing
Landscape Irrigation: Parks, play fields, cemeteries, median strips, golf courses
Agricultural Irrigation: Irrigation of commercially-grown crops
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

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.”

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

COMMENTS:

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

GROUNDWATER SOURCES (INCLUDING STANDBY SOURCES)

PSCode	Name	Activity

Add sources not listed above. Describe changes to sources above under "Comments".

PSCode	Name	Activity	Comments
				1 - 6 of 6

SURFACE WATER INTAKES

PSCode	Name	Activity

Add sources not listed above. Describe changes to sources above under "Comments".

PSCode	Name	Activity	Comments
				1 - 6 of 6

Are your water sources metered? --Pick one-- Yes No

DISCUSS CHANGES TO ABOVE SOURCES

If 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 DDW 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 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 the Maximum Day ONLY: --Pick one-- Gallons Million Gallons Acre-feet (AF) 100 cubic feet

Mark this box if your water system does not have monthly production data.

If you do not have monthly production data to report, please report your Annual Total production in the row for January and leave all the other months blank.

Units of Measure for this table except for the Maximum Day: --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
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, 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 flouridation.

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.

Mark this box if your water system does not charge a water rate and skip the rest of Section 6a.

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 rate structure used in the Comments box) We Do Not Charge A Water Rate (specify why in the Comments box)

If tiered, what is the number of tiers?	--Pick one-- Not Tiered 2 3 4 5 6 7
Date of most recent update to the rate structure: MM/DD/YYYY
Describe the changes that were made in the update:
What is your billing frequency --Pick one-- monthly bi-monthly quarterly annually other
What is your new connection fee?
Date of most recent update to the new connection fee: MM/DD/YYYY

Complete the table below providing specific water rates applied to your 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
RESIDENTIAL
Single-family Residential
Multi-family Residential
Do you provide lifeline/low income subsidies?			--Pick one-- Yes No
If Yes, provide rates:
If yes, what percentage of residential customers receives this subsidy? (Example: X %)				%
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
What are the other surcharges?
If Yes, provide rates:

For each of the three water volumes shown below, provide what would be the monthly water bill for a single-family residential customer.
Include all fees and service charges associated with water services that this customer would pay when their household used the specified amount of water.

Amount of water delivered to customer:	Bill amount (including all charges/fees associated with the amount of water used):
a. 6 HCF	Dollars/month
b. 12 HCF	Dollars/month
c. 24 HCF	Dollars/month

NOTE: If this is not a "Community" Water System or if individual customers do not pay a separate bill for water enter "0".
If bill amount would vary by season, use the month or time period with the highest water consumption.

HCF means “hundred cubic feet”. There are 748 gallons in 100 cubic feet.

6b. WATER DELIVERIES

Mark this box if your water system does not have monthly water deliveries data and skip the rest of Section 6b.

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 (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:

COMMENTS:

8. WATER TREATMENT

Treatment Plant	Required Treatment Plant Operator Classification
		1 - 4 of 4

If treatment was added or changed in any way in 2017, provide a brief description and identify the water source

TD = Treatment or Distribution operator at any level

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

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 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)
Backflow Assemblies On-site but not on the Service Connections or Meter (Reduced Pressure Principle and Double Check Valve assemblies)
Air-gap Separation

No. of Inactive Backflow Prevention Assemblies in water system in 2017 :
Date of last cross-connection control survey done on the system:
Cross Connection Control Program Coordinator
Name:
Certification Number:
Business Phone:		Email Address:
Certification or training received:

Describe any cross-connection incidents that occurred during 2017:

COMMENTS:

10. 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:

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:  

If you do not have a Certified Distribution System Operator, put "NONE" in each column of the first row.

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):
Treatment Operator Number (4 or 5 digits):
Treatment Certification Expiration Date (MM/DD/YYYY):

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:  

If you do not have a Certified Distribution System Operator, put "NONE" in each column of the first row.

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):
Distribution Operator Number (4 or 5 digits):
Distribution Certification Expiration Date (MM/DD/YYYY):

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:

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

Indicate any planned improvements or modifications for 2018.

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 the Division of Drinking Water or Local County Staff	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 the Division of Drinking Water or Local County Staff	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 USEPA, Division or LPA enforcement for 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 2017 that public notification was provided to users
Corrective action taken in 2017
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 or Water Shortage Contingency Plan, if any:
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:
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:       volume of water in units selected for this section       % 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:

COMMENTS:

17. 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

18. 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.html

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):

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
B. Unknown material
C. Copper
D. Cast iron (ductile pipe)
E. Ductile iron
F. Galvanized steel
G. Polyvinyl chloride (PVC)
H. Polyethylene (PE)
I. High density polyethylene (HDPE)
J. Polybutylene (PB)
K. Transite/asbestos cement
L. Other materials not listed above:
Identify material 1
Identify material 2
Identify material 3
Identify material 4
Total number of service lines inventoried* (calculated field)
Total number of service connections from Section 3 of the EAR
Fittings or fittings connecting a water main:
M. Lead fittings NOT on a lead pipe(e.g., goosenecks, pigtails, and corporation stops)
N. Lead fittings ON a lead pipe (e.g., goosenecks, pigtails, and corporation stops)
O. Fittings of unknown material (e.g., goosenecks, pigtails, and corporation stops)
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:
Date signed (MM/DD/YYYY):
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.