Self Monitoring Form for Industrial Uses

Redwood City Recycled Water Project Self Monitoring Monthly Inspection Report Commercial and Industrial Uses

Contact Information

Red Indicates a Required Field

Site Name:
Site Number:
Site Supervisor:
Site Address:
Has the Site Supervisor changed since the last report? Yes
No

If so, provide name, phone number and e-mail address:

Supervisor's Telephone:
Supervisor's E-mail:
Observation Date:

(mm/dd/yy)

List the commercial and industrial applications on site:
    Required
1. Is there any evidence at meter locations of the recycled water and potable water lines that modifications were made? Yes
No
N/A
2. Is there evidence of any signs of or visible cross connections? Yes
No
N/A
3. Are all valve tags, signage and equipment marking in place, visible, and undamaged? Yes
No
N/A
4. Is there evidence of leaks, breaks, or plugs in the system pipelines or other appurtenances? Yes
No
N/A
5. Are all valve lock seals in place and intact? Yes
No
N/A
6. Are all recycled water signs, tags, stickers, and above ground markings properly located, visible, and legible? Yes
No
N/A
7. Are all maintenance records up to date? Yes
No
N/A
8. Is the on-site back-up water supply in operable condition? Yes
No
N/A
9. If there is a cooling tower on site that uses recycled water, is the drift eliminator functioning properly? Yes
No
N/A
10. If there is a cooling tower on site that uses recycled water, is biocide applied as required? Yes
No
N/A
11. Is there any evidence of recycled water escaping the use area through surface runoff or airborne spray? (If yes, explain in the box at the bottom of this form.) Yes
No
N/A
12. Are there any odors resulting from the use of recycled water? (If yes, note source, characterization and travel distance in the box at the bottom of this form.) Yes
No
N/A
13.

 

 Is there evidence of direct spraying of recycled water on people, streams, passing vehicles, buildings, domestic water facilities (such as drinking fountains), or food handling facilities? Yes
No
N/A

If the answer is “yes” to any of the above questions, describe the situation below. Indicate the date that the problem was noticed, the specific location within the site that the problem occurred, and the corrective action taken.