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Form 1-1 Operational Checklist: System description (SD

)
(This form is used for the initial system evaluation for the facility and the site. It should be kept on file, and a copy should accompany the service provider at each O&M service visit. Any changes to the system facility should be recorded on the form, along ith the date the change as noted.!

A. Client Contact Information
Name of owner: Phone: Cell: Site address/County: Mailin address/County !if different": #irections to site: System ref. #: T: R: Sec: E-mail: No.:

. System Doc!mentation A"aila#le !$f no documentation% fill out Section #."
#ate installed: $nstaller: Phone: E-mail: #esi ner: Phone: E-mail: Pre)ious ser)ice *ro)ider: Phone: E-mail: #esi n flow: Cell: &icense #: 'a(: &icense #: 'a(: &icense #: 'a(:

Cell:

Cell: +al *er day

C. Operational Checklists
Identify operational checklists for components included in system. "umber the components of the treatment train in order in the spaces provided after the titles. Form $.1 Site Assessment on 'ile. ,es No

%anks and ad"anced treatment component operational checklists (Chapters &' ( and )): Pum*: #emand-#osed system: Pum*: Timer-#osed system: /oldin tan0: Se*tic/trash/*rocessin !tan0": Pum* tan0!s": -ero.ic treatment unit: Constructed wetland: &a oon: #isinfection unit 1chlorine: #isinfection unit 1ultra)iolet li ht:

er lass Plastic 3ther ...er of ... Softener . #: Final treatment and dispersal component operational checklists (Chapter *): +ra)ity #istri..... Num. +o System Doc!mentation A"aila#le #omplete the remaining information if it is not available in the permit or as$built dra ings. -re any water softener or water treatment chemicals used.... 43# !m /&" . Num.surface/ ra)ity Su...surface/*um* . /oldin tan0 5" Ca*acity: 6" Material: Concrete i" Manufacturer: 8" -ccess to surface.es . S7uare foota e of facility: s7 ft 8. 9" &ocation !+$S": . Softener .. #esi n flow: *d :.ed: Mound system: 4ottomless sand filter: &ow-*ressure drainfield: S*ray field: 3utfalls: 4ottomless *eat filter: D.. &andsca*e *osition: .es . Facility Details 5.a e dis*osal *resent.": +ar.. @.. Monitorin well *resent. =ater su**ly: Pri)ate water su**ly >.ution: #ri* field: E)a*otrans*iration .Media filter: #isinfection unit 1o2one: System ref.lic water su**ly =ater source !if *ri)ate su**ly": +roundwater well: ft S*rin : Surface water !i.ac0wash does not drain to system: 5A...es .es No / .. Site a.. Pu. '3+ !m /&" <.....TSS !m /&" .een remodeled since ori inal construction. .. cree0% la0e% etc. #raina e: Surface/ ra)ity c..ac0wash drains to system: &ateral distance to water su**ly ft ft . -retreatment components . /as facility .. System Details 1..es . #esi n stren th: .es No al 'i...%anks a.e. Se*tic tan0 /Trash tan0 Su...er of current occu*ants: 9..edrooms: 6.es No No No No No ?.

al/dose Model: .es No / N... ii" 4rea0er si2e: 56" -larm i" Manufacturer: ii" Sensors: 'loats Pressure transducer iii" #escri*tion: #osin *um* tan0 5" Ca*acity: 6" Material: Concrete 8" -ccess to surface.er lass i" Manufacturer: 8" -ccess to surface...... ii" Ca*acities for com*artmented system: 6" Material: Concrete 'i. 9" &ocation !+$S": :" #osin tan0: i" Manufacturer: <" Pum*: i" Manufacturer: >" Pum* o*eratin condition i" #ischar e Rate: ii" /ead: al/in . 9" &ocation !+$S": :" Effluent screen. al 5" Plastic 3ther System ref. Model: /P: al/min ft ... sec/dose ." 5" Ca*acity: 6" Material: Concrete 'i.er lass Plastic . N..-..es No / N... #: ..es No Bltrasonic 3ther d..er lass Plastic 8" -ccess to surface. i" Manufacturer: c. Model: /P: al/min ft Bltrasonic 3ther .5" Ca*acity !total": i" Com*artmented..es Model: No / No .. doses/day .-.-. al/in 'i.. N..es .. 9" &ocation !+$S": :" Pum* tan0: i" Manufacturer: <" Pum*: i" Manufacturer: >" Pum* o*eratin condition i" #ischar e Rate: ii" 3*eratin Pressure: ?" Control method i" Sensors: 'loats Pressure transducer ii" #escri*tion: @" Pum* dose settin s i" 're7uency ii" $nter)al iii" Colume 5A" Control *anel i" Manufacturer: 55" Electrical i" Se*arate circuits !*um*% alarm".-..es No al 6" al 'low e7uali2ation tan0 !sur e% etc.....

er lass i" Manufacturer: ii" Product serial #: 9" -ccess to surface..ility: 4uried iii" Co)er material: i)" &id insulated.-... :" &ocation !+$S": <" Effluent screen / Tertiary filter i" Manufacturer: >" -ir su**ly i" -ir su**ly method: -s*irator ii" Manufacturer: ?" Slud e return method: ...ic treatment unit !-TB" 5" Treatment method: Sus*ended rowth -ttached rowth Com....es No / N.es No in +ra)ity . #: ii" $nter)al: iii" Colume: 5A" Panel for sensors i" Manufacturer: 55" Electrical i" Se*arate circuits !*um*% alarm".. al/dose Model: . -retreatment components / ad"anced a.es No Bltrasonic 3ther Rotatin 4iolo ical Contactor Se7uencin 4atch Reactor *d Plastic Model #: ... doses/day 'loats Pressure transducer Bltrasonic 3ther System ref.....ution method: Pressure i" Pi*e diameter: .. ii" 4rea0er si2e: 56" -larm i" Manufacturer: ii" Sensors: 'loats Pressure transducer iii" #escri*tion: ..... Com*ressor 4lower Model #: 'ree -ir 'oam Peat 3ther: in ft ( s7 ft ft 'ree -ccess Co)ered .. 8" #istri.?" Control method i" Sensors: ii" #escri*tion: @" Pum* dose settin s i" 're7uency: ..ination attached/sus*ended rowth 3ther: 6" Ca*acity: 8" Material: Concrete 'i.. Sin le *ass filter 5" Media: Sand +lass i" Media de*th: ii" &iner material: 6" 'ilter si2e: i" #imensions: ii" -ccessi.. -ero. sec/dose .

es No No .er )ii" Clean out access to surface. 9" 'iltrate collection system: ii" 'low control: in in .": )" S7uirt hei ht/3*eratin Pressure: )i" Clean outs/$ns*ection *orts: Num.3rifice S*ray no22le 3ther: 3rifice orientation: iii" 'low control diameter: i)" Num.er of flow controls !orifices% no22les% etc.es .

es .System ref.-.-. Tric0lin filter 5" Media: +ra)el 'oam Te(tile Plastic 3ther: i" Media de*th: ii" &iner material: 6" 'ilter si2e: i" #imensions: 8" #istri.": )" S7uirt hei ht/3*eratin Pressure: )i" Clean outs/$ns*ection *orts: Num. +ra)el 3ther: in in s7 ft . 9" 'iltrate collection system: :" 'orced aeration: i" #escri*tion: Constructed wetland 5" 4ed media: None i" Num.es .er )ii" Clean out access to surface. #istri.es No No N.es No in in in .er )ii" Clean out access to surface.ution method i" Pi*e diameter: ii" 'low control: 3rifice S*ray no22le 3ther: 3rifice *osition: iii" 'low control diameter: i)" Num. Recirculatin 'ilter 5" Media: Sand +ra)el Polystyrene 4ottom -sh 'oam Te(tile in s7 ft ft 6" 8" 9" :" d. 3ther: i" Media de*th: ii" &iner material: iii" Recirculation method: 'ilter si2e: i" #imensions: ii" -ccessi.": )" S7uirt hei ht/3*eratin head: )i" Clean outs/$ns*ection *orts: Num.er of flow controls !orifices% no22les% etc.es No No N. 'iltrate collection system: 'orced aeration: i" #escri*tion: ft ( .er of cells: ii" Media de*th: iii" =ater de*th: i)" &iner material: )" 4order material: 6" Si2e: in ft ( s7 ft ft in in in .ution method i" Pi*e diameter: ii" 'low control: 3rifice S*ray no22le 3ther: 3rifice *osition: iii" 'low control diameter: i)" Num. #: c.er of flow controls !orifices% no22les% etc. e.ility: 4uried 'ree -ccess iii" Co)er material: i)" &id insulated.

#: ft ( ft ii" &en th to width ratio: 8" #istri.i" #imensions: System ref. #isinfection unit 5" Chlorine 1 ta. 9" Surface loadin rate: :" 'iltrate collection system: <" Monitorin location: >" Ce etation: i" #escri*tion: ?" =ater le)el control: i" #escri*tion: f. Partial-mi(ed aerated -naero.-.ution method i" Pi*e diameter: ii" 'low control: 3rifice S*ray no22le 3ther: 3rifice *osition: iii" 'low control diameter: i)" Num.-.es .es in No No *d/s7 ft N. 9" Surface loadin rate: :" Monitorin location: <" Ce etation: i" #escri*tion: >" =ater le)el control: i" #escri*tion: : in in .er of flow controls !orifices% no22les% etc.let i" Manufacturer: 6" Chorine 1 li7uid i" Manufacturer: 8" Bltra)iolet li ht i" Manufacturer: 9" 32one i" Manufacturer: :" 3ther: <" #isinfection monitorin location: >" #echlorination i" Ty*e: ii" Manufacturer: ?" #echlorination monitorin location: Model: Model: Model: Model: Model: . .ic ft ft ( : s7 ft ft .er )ii" Clean out access to surface. &a oon system 5" Ty*e: -ero. N.-. N.es in No *d/s7 ft N.ic 'acultati)e i" =ater de*th: ii" &iner material: 6" &a oon si2e: i" #imensions: ii" &en th to width ratio: 8" $nlet to la oon i" Pi*e descri*tion: ii" Pi*e diameter: iii" Clean outs.-.": )" S7uirt hei ht/3*eratin Pressure: )i" Clean outs/$ns*ection *orts: Num.

ii" Num.er of orifices: d" S7uirt hei ht/3*eratin head: e" Clean outs/$ns*ection *orts: Num.er of trenches/.es .ra)ity Se7uential Ste*down 9" #istri.o( Solid header *i*e #ro* .eds: iii" #imensions of trenches/.er of orifices: e" S7uirt hei ht/3*eratin head: f" Clean outs/$ns*ection *orts: Num.er of 2ones: a" $f multi*le% switchin de)ice: . #: $.surface ii" #ri* tu.ution i" #istri..es No No ft ( ft s7 ft .ution method a" Pi*e diameter: .in manufacturer: Model: iii" 'iltration: Screen #is0 Sand Manufacturer: Model: i)" 'ilter cleanin : -utomated Manual/Continuous flush )" Num.eds: #ri* distri.er of trenches/." 3rifice diameter: c" Num.System ref.o( :" #istri." Done area!s": s7 ft s7 ft in in in .es .ution field: Surface Su.ution 5" Ty*e: Trench 4ed i" $f lined ET .er f" Clean out access to surface." 3rifice diameter: c" 3rifice orientation: d" Num.ra)ity 8" Confi uration: Parallel ET . Pressure 5" &ow-*ressure drainfield i" &e)el.eds: )" #imensions of trenches/.er of 2ones: a" Switchin method: Polystyrene 3ther: .ed Pum*-to.ution a**roach: #istri.ution method: Trench 4ed 3ther: a" Pi*e diameter: . i)" Num. Final treatment and dispersal a. ii" Num.ution .eds: Pressure mound distri.es No No ft ( ft in in in .e liner material: 6" #istri. +ra)ity distri.er " Clean out access to surface.ution media i" Material: +ra)elless Multi-*i*e Cham.ed% descri.ra)ity Serial Si*hon-to.ution i" #istri.es /ydraulic )al)es Se*arate *um*s No 6" 8" 3ther: iii" #istri.ution method: +ra)ity-to.er =ashed roc0 .

)i" 'ield flushin : -utomated )ii" -ir release/Cacuum . System ref." Pattern!s": iii" $n-line filtration: None Screen a" Manufacturer: i)" Total area of s*ray distri. #: )iii" $ns*ection *orts. a" &ocations: 9" S*ray field i" Num.er of 2ones: a" $f multi*le% switchin de)ice: ii" #istri.er: ii" Permit re7uirements: iii" &ocation: i)" Monitorin location: .es No Model!s": #is0 Sand Model: s7 ft .rea0er: a" Manufacturer: Continuous Model: Manual N.ution heads *er 2one: a" Manufacturer: .-.ution fields: )" +au in #e)ice: :" Surface dischar e i" Permit num.

. #: 0.....System ref. Sketch of system Scale 5 in E . ft ..