LPE Form

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Utility Name __________________ Utility ID __________________ CDC Event ID __________________

Low Pressure Event FORM

1. Does this event affect at least 10 residential units? Yes (Please continue to question 2) No (This event is not eligible for study)

2. Date and time event reported:

_____/_____/_____ _____:____ AM or PM

mm dd yY hr MIN (Circle)

3. Date and time repair crew arrived on site:

_____/_____/_____ _____:____ AM or PM

mm dd yY hr MIN (Circle)

4. Date and time repair completed:

_____/_____/_____ _____:____ AM or PM

mm dd yY hr MIN (Circle)

5. Location: ______________________ ____________________ _______

Street City State

6. Cross streets: __________________________________________________

7. GPS coordinates: ___________________ ___________________

Latitude Longitude

8. Main housing type:

Single family homes Apartments/condos Mobile homes

Other/mixed (Describe________________________________________)

Infrastructure information

9. Diameter of pipe: _________ Inches

10. Age of the pipe: ___________Years

11. Depth of pipe? _____Feet ___Inches

12. Describe soil (e.g. sand, clay, dirt, rock backfill): ___________________________________

___________________________________

13. Origin of water (Name of water storage facility, well, or plant):_________________________

_______________________________

14. Pipe material (Check one):

Asbestos Cement Cast iron Concrete Ductile Iron Galvanized

HDPE PVC Steel Wood Don’t know

Other (Describe: _________________________________________________)

15. Interior condition (1- Smooth  5- Highly tuberculated): 1 2 3 4 5

Comments on condition of pipe: ____________________________________________ ________________________________________________________________________________________________________________________________­______________

15

EVENT Information

16. What type of event occurred?

Planned main repair Main break Pump station outage Other maintenance activity (Describe________________)

17. Describe the reason for the cause of low pressure: (check all that apply):

Water Hammer (Surge) Defective Pipe Deterioration Corrosion

Excessive Operating Pressure Temp. Change Differential Settlement

Contractor Main break Contractor Valve Shutoff Pumping Changes Accident

Other (Describe:____________________________________________________________________)

18. If main break, please describe the nature of the break:

Circumferential Longitudinal Both circumferential and longitudinal Blowout Joint Sleeve

Split at Corporation Other (Describe:_____________________________________________________)

EVENT Impact

19. Number of households affected by break/repair: _______________________

20. Was there a loss of household water service? Yes No 20a. Num. of households lost service: __________

20b. Date/time of lost service: _____/_____/_____ _____:____ AM or PM (Circle)

mm dd yY hr MIN

20c. Date/time service restored: _____/_____/_____ _____:____ AM or PM (Circle)

mm dd yY hr MIN

21. Were service branches tuned off? Yes No 21a. Num. of residential units out of service__________

21b. Date/time turned off: _____/_____/_____ _____:____ AM or PM (Circle)

mm dd yY hr MIN

21c. Date/time restored: _____/_____/_____ _____:____ AM or PM (Circle)

mm dd yY hr MIN

Public reporting burden of this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).

22. Pressure reading during and after event:

Hose Bib Location	Approximate distance (in yards)	Pressure during event (PSI)	Date	Time	Pressure after cleanup of break/repair (PSI)	Date	Time
Nearest connection to break/repair			_____/_____/_____ MM DD YY	____:___ AM OR PM HR MM		_____/_____/_____ MM DD YY	____:___ AM OR PM HR MM
Upstream			_____/_____/_____ MM DD YY	____:___ AM OR PM HR MM		_____/_____/_____ MM DD YY	____:___ AM OR PM HR MM
Downstream			_____/_____/_____ MM DD YY	____:___ AM OR PM HR MM		_____/_____/_____ MM DD YY	____:___ AM OR PM HR MM

23. Normal pressure at break/repair location from hydraulic model (if available):________________________

Water Pressure

REPAIR PROCESS

24. What type of repair was conducted? Clamp repair Cut and replace section of pipe Replace or repair fitting

Flush valve or backflow valve replacement Other (Describe:_______________________________________________)

25. Was the pipe ever submerged in trench water while repairs were being made? Yes No

25a. What type of water was it? (e.g. rain, sewage, groundwater): ____________________________________

26. Describe precipitation while the main was being repaired. Heavy Rain Light Rain Snow or Sleet None

27. Are sewage or reclaimed water lines adjacent or in close proximity to the main being repaired? If yes, please specify the approximate distance (in feet) that separates the water main and the sewage or reclaimed water line:

Sewage line present	Reclaimed Water line present
Horiz. Dist. _____ Feet Vert. Dist. _____ Feet	Horiz. Dist. _____ Feet Vert. Dist. _____ Feet
Breaks, breaches, or leaks in line? Yes No	Breaks, breaches, or leaks in line? Yes No

28. Were replacement parts swabbed prior to being installed? Yes No N/A

29. Was the main flushed before being brought back into service? Yes No N/A

29a. Describe flushing process (e.g. estimated velocity and duration): ____________________________________

30. Was the main chlorinated before being brought back into service? Yes No N/A

30a. What was disinfectant residual of bulk water in the main before being brought into service? ____________

31. Was a boil-water advisory (BWA) or notice administered as a result of this event? Yes No

31a. When was BWA issued? _____/_______/______ time: ______: ______ AM or PM

Mm dd yr hr min (Circle)

31b. When was BWA lifted? _____/_______/______ time: ______: ______ AM or PM

Mm dd yr hr min (Circle)

31c. How was the BWA communicated to the public? (check all that apply)

Television Radio Phone calls Door hanger/leaflet E-mail

Other (Describe________________________________________________________________)

32. What is your assessment of the potential for contamination? Low Moderate High

Please elaborate on why you selected low, moderate, or high: ______________________________________________

_________________________________________________________________________________________________

33. Do you have any other comments about the low pressure event or extent of BWA?

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

WATER SAMPLE COLLECTION DATA SHEET

SAMPLE ID: ___________________________________ Date & Time: ____________________Collected By: ____________________

Location of sample (address or GPS coordinates): ___________________________________________________________________

Pipe material at service connection: ______________________________ Area: Affected Unaffected

Field water temperature:	oC	Total or Residual chlorine (Circle):	mg/L
pH:		Conductivity:	µS/cm
Grab sample collected?	Yes No	Preserved w/ Sodium Thiosulfate?	Yes No
Filtration meter start reading:		Filtration start time:
Filter 100 liters	+ 26.4 gallons =	Filtration end time:
Stop filtration meter reading:		Preserved w/ Sodium Thiosulfate?	Yes No

SAMPLE ID: ___________________________________ Date & Time: ____________________Collected By: ____________________

Location of sample (address or GPS coordinates): ___________________________________________________________________

Pipe material at service connection: ______________________________ Area: Affected Unaffected

Field water temperature:	oC	Total or Residual chlorine (Circle):	mg/L
pH:		Conductivity:	µS/cm
Grab sample collected?	Yes No	Preserved w/ Sodium Thiosulfate?	Yes No
Filtration meter start reading:		Filtration start time:
Filter 100 liters	+ 26.4 gallons =	Filtration end time:
Stop filtration meter reading:		Preserved w/ Sodium Thiosulfate?	Yes No

SAMPLE ID: ___________________________________ Date & Time: ____________________Collected By: ____________________

Location of sample (address or GPS coordinates): ___________________________________________________________________

Pipe material at service connection: ______________________________ Area: Affected Unaffected

	Field water temperature:	oC		Total or Residual chlorine (Circle):				mg/L
	pH:			Conductivity:				µS/cm
	Grab sample collected?	Yes No		Preserved w/ Sodium Thiosulfate?				Yes No
	Filtration meter start reading:			Filtration start time:
	Filter 100 liters	+ 26.4 gallons =		Filtration end time:
	Stop filtration meter reading:	____________________		Preserved w/ Sodium Thiosulfate?				Yes No
SIGNATURE:			PRINT NAME:		DATE:	TIME:	SAMPLE CONDITION:
RELINQUISHED BY:							(FOR LAB USE ONLY)
							Actual Temperature:
RECEIVED BY:							Received On Ice		Y / N
RELINQUISHED BY:							Preserved		Y / N
RECEIVED BY:							Seals Present		Y / N
COMMENTS/FIELD OBSERVATIONS: PLEASE SHIP SAMPLES ON ICE TO KEEP COLD DURING OVERNIGHT SHIPMENT							Container Intact		Y / N
							Preserved at Lab		Y / N

WATER SAMPLE COLLECTION DATA SHEET

SAMPLE ID: ___________________________________ Date & Time: ____________________Collected By: ____________________

Location of sample (address or GPS coordinates): ___________________________________________________________________

Pipe material at service connection: ______________________________ Area: Affected Unaffected

Field water temperature:	oC	Total or Residual chlorine (Circle):	mg/L
pH:		Conductivity:	µS/cm
Grab sample collected?	Yes No	Preserved w/ Sodium Thiosulfate?	Yes No
Filtration meter start reading:		Filtration start time:
Filter 100 liters	+ 26.4 gallons =	Filtration end time:
Stop filtration meter reading:		Preserved w/ Sodium Thiosulfate?	Yes No

SAMPLE ID: ___________________________________ Date & Time: ____________________Collected By: ____________________

Location of sample (address or GPS coordinates): ___________________________________________________________________

Pipe material at service connection: ______________________________ Area: Affected Unaffected

Field water temperature:	oC	Total or Residual chlorine (Circle):	mg/L
pH:		Conductivity:	µS/cm
Grab sample collected?	Yes No	Preserved w/ Sodium Thiosulfate?	Yes No
Filtration meter start reading:		Filtration start time:
Filter 100 liters	+ 26.4 gallons =	Filtration end time:
Stop filtration meter reading:		Preserved w/ Sodium Thiosulfate?	Yes No

SAMPLE ID: ___________________________________ Date & Time: ____________________Collected By: ____________________

Location of sample (address or GPS coordinates): ___________________________________________________________________

Pipe material at service connection: ______________________________ Area: Affected Unaffected

	Field water temperature:	oC		Total or Residual chlorine (Circle):				mg/L
	pH:			Conductivity:				µS/cm
	Grab sample collected?	Yes No		Preserved w/ Sodium Thiosulfate?				Yes No
	Filtration meter start reading:			Filtration start time:
	Filter 100 liters	+ 26.4 gallons =		Filtration end time:
	Stop filtration meter reading:	____________________		Preserved w/ Sodium Thiosulfate?				Yes No
SIGNATURE:			PRINT NAME:		DATE:	TIME:	SAMPLE CONDITION:
RELINQUISHED BY:							(FOR LAB USE ONLY)
							Actual Temperature:
RECEIVED BY:							Received On Ice		Y / N
RELINQUISHED BY:							Preserved		Y / N
RECEIVED BY:							Seals Present		Y / N
COMMENTS/FIELD OBSERVATIONS: PLEASE SHIP SAMPLES ON ICE TO KEEP COLD DURING OVERNIGHT SHIPMENT							Container Intact		Y / N
							Preserved at Lab		Y / N