Fillable Annual Report Template - Small To Mid-size (Island Health)

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Annual Report Template - Small To Mid-size (Island Health)

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The Annual Report Template - Small To Mid-size (Island Health) form is 4 pages long and contains:

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  • 31 check-boxes
  • 111 other fields

Country of origin: CANADA
File type: PDF

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PAGE 1 OF 4
DRINKING WATER SYSTEM ANNUAL REPORT
DRINKING WATER SYSTEM ANNUAL REPORT
Reporting Period:
January 1
st
to December 31
st
, (year)
Water System
Water System Owner
Primary Contact Name (Operator or Manager)
Phone Number (Operator or Manager)
E-mail (Operator or Manager)
DESCRIBE YOUR WATER SUPPLY SYSTEM
What is the Source(s) of Raw Water?
Deep Well
Shallow Well
Other
If other, specify details:
Does the Drinking Water System have Primary Disinfection?
Yes
No
Chlorination
Ultraviolet Light
Other
If other, specify details:
Does the Drinking Water System have Secondary Disinfection?
Yes
No
Chlorination
Other
If other, specify details:
Does the Drinking Water System have Filtration?
Yes
No
Check all boxes that apply
Cartridge Filter(s)
Carbon Filter
Reverse Osmosis
Other
If other, specify details:
PUBLIC REPORTING
Emergency Response & Contingency Plan (ERCP)
Is your ERCP up to Date?
No
How do you Inform the System Users of the ERCP?
Hand Delivered
Bulletin Board
Utility Bill Insert
Website
Other (specify details)
Drinking Water System Annual Report
How do you Inform the System Users of the Annual Report?
Hand Delivered
Bulletin Board
Utility Bill Insert
Website
Other (specify details)
PAGE 2 OF 4
DRINKING WATER SYSTEM ANNUAL REPORT
COMPLIANCE WITH OPERATING PERMIT
List the conditions of your Operating Permit (Contact the DWO for a copy if needed):
Are you in compliance with your Operating Permit?
Yes
No
BACTERIOLOGICAL TESTING AND DRINKING WATER PROTECTION REGULATION WATER QUALITY STANDARDS
How many bacteriological samples were collected during this reporting period?
What is the minimum required sampling frequency for this system? (#samples/month)
Additional sampling details:
Was the minimum required sampling frequency achieved?
Yes
No
Comments:
Bacteriological summary attached to this report?
Yes
No
If no, how do the users of the system view the results?
WATER QUALITY STANDARDS FOR POTABLE WATER
Parameter:
Standard:
Did this system meet standard?
Escherichia coli
(for all samples)
No detectable Escherichia coli per 100ml
Yes
No
Total Coliform Bacteria
(if only 1 sample collected in a 30
day period)
No detectable total coliform bacteria per 100ml
Yes
No
Total Coliform Bacteria
(if more than 1 sample collected in a
30 day period)
No more than 10% of samples contain total
coliform bacteria, and No sample has more than
10 total coliform bacteria per 100ml
Yes
No
If the system did not meet any of above Drinking Water Protection Regulation standards, record the results in
the table below; attach additional sheets if necessary.
Date
TC/100ml
E.coli/100ml
Reason
Corrective Action
PAGE 3 OF 4
DRINKING WATER SYSTEM ANNUAL REPORT
CHEMICAL SAMPLING COMPLETED DURING THIS REPORTING PERIOD
Was any chemical sampling conducted during reporting period?
Yes
No
If no, when were the last chemical samples conducted for this system? (date)
Don’t know
If yes, attach a list of the chemical results
If any water samples did not meet the Guidelines for Canadian Drinking Water Quality, record the results in
the table below; attach additional sheets if necessary.
Next scheduled full chemical test (date)
Parameter
Result
Corrective Action / Treatment / Comments
ADDITIONAL TESTING
Does the system have analyzers for continuous monitoring?
Yes
No
If yes, check all boxes that apply:
Chlorine
Turbidity
Are the results available on request?
If any additional testing or sampling was conducted, record results in the table below; attach additional
sheets if necessary.
Additional Testing & Reason for Sampling
Corrective Action Taken
WATER QUALITY COMPLAINTS
Were there any water quality complaints in this reporting
period? (e.g. taste, odour, colour etc.)
Yes
No
If yes, complete the table below; attach additional sheets if necessary.
Date
Water Quality Complaint
Corrective Action / Treatment
PAGE 4 OF 4
DRINKING WATER SYSTEM ANNUAL REPORT
OPERATIONAL PROBLEMS
Were there any operational problems during this reporting
period? (e.g. insufficient water supply, malfunction of
disinfection equipment, line breaks, elevated turbidity etc.).
Yes
No
If yes, complete the table below; attach additional sheets if necessary.
Incident Date
Type of Operational Problem
Corrective Action Taken
MAJOR UPGRADES/REPAIRS & EXPENSES
Were there any major upgrades/repairs or any major costs
incurred during this reporting period?
Yes
No
If yes, complete the table below; attach additional sheets if necessary.
Major Upgrades/Expenses
Details
Improvements required by DWO
Additions/changes to system
Purchase or install new equipment
Equipment repair or replacement
Annual maintenance of system
Specialist report
Other
FUTURE IMPROVEMENTS
Are there any plans for future improvements?
Yes
No
If yes, complete the table below; attach additional sheets if necessary.
Future Upgrades or Improvements
Estimated Date of Completion
Click here to enter a date.
DATE COMPLETED:
COMPLETED BY:
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Annual Report Template - Small To Mid-size (Island Health)

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Completed 25 November 2020

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