&EPA
  United States
  Environmental Protection
  Agency
Wastewater Response Protocol
Toolbox:
Planning For and Responding To
Wastewater Contamination
Threats and Incidents
December 2011
Appendices

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                                Initial Threat Evaluation
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                                 Site Characterization

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                                     Public Health

                                   Response Actions
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                       Table of Contents - Appendices

Module 2 Forms
1 Response Planning Matrix	Al
2 Threat Evaluation Worksheet	A2
3 Security Incident Report Form	A3
4 Witness Account Report Form	A4
5 Phone Threat Report Form	A5
6 Written Threat Report Form	A6
7 Public Health Information Report Form	A7
Module 3 Forms
8 Site Characterization Plan Template	A8
9 Site Characterization Report Form	A9
10 Field Testing  Results Form	AID
11 Sample Documentation Form	All
12 Chain of Custody Form	A12
Module 5 Forms
13 Contaminant Characterization and Transport Worksheet	A13
14 Public Health Response Action Worksheet	A14
Module 6 Forms
15 Suggested Outline for System Characterization/Feasibility Study Work Plan	A15
16 Elements for a Quality Assurance Project Plan	A16
17 Elements of a Health and Safety Plan	A17
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    1 Response Planning Matrix
Incident
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Possible
Credible
Con Firmed
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Health
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Moderate
Severe
Minor
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Severe
Minor
Moderate
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Minor
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Severe
Minor
Moderate
Severe
Minor
Moderate
Severe
Minor
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 2 Threat Evaluation Worksheet

 INSTRUCTIONS

 The purpose of this worksheet is to help organize information about a contamination threat
 warning that would be used during the Threat Evaluation Process. The individual responsible for
 conducting the Threat Evaluation (e.g., the Utility Incident Commander) should complete this
 worksheet.  The worksheet is generic to accommodate information from different types of threat
 warnings; thus, there will likely be information that is unavailable or not immediately available.
 Other forms in the Appendices are provided to augment the information in this worksheet.


Threat Warning Information

          Date/Time threat warning discovered: 	
          Name of person who discovered threat warning:	

          Type of threat warning:
           D  Security breach   D  Witness account    D  Phone threat
           D  Written threat    D  Law enforcement   D  Public health notification
           D  News media      D  Public complaints
           D  Degradation of treatment organisms
           D  Unusual wastewater chemical characteristics
           D  Other:	


          Identity of the contaminant:          D Known     D Suspected    D Unknown

            If known or suspected, provide additional detail below
           D  Chemical           D  Biological            D  Radiological

           Describe:
          Time of contamination:       D Known    D Estimated     D Unknown
                                                                                                      CO
            If known or suspected, provide additional detail below                                                        QJ
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          Date and time of contamination:	            -~~

          Additional information:	
                                                                                                      Q_
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          Mode of contamination:       D Known    D Suspected     D Unknown
            If known or suspected, provide additional detail below

          Method of addition:     D Single dose     D Over time     D Other	

          Amount of material:	
          Additional information:
                           Wastewater Response Protocol Toolbox                        A2-1

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              Site of contamination:           D Known     D Suspected    D Unknown

                 If known or suspected, provide additional detail below
                 Number of sites:
                 Provide the following information for each site.
                 Site #1
                 Site Name:
                 Type of facility:
                 D  Manhole              D  Treatment plant               D  Pump station
                 D  Catch basin            D  Collection main               D  Building drain
                 D  Other:	
                 Address:	
                 Additional site information:
                 Site #2
                 Site Name:
                 Type of facility:
                 d  Manhole              D  Treatment plant               D  Pump station
                 D  Catch basin            D  Collection main               D  Building drain
                 D  Other:	
                 Address:	


                 Additional site information:
CO               Site #3
CD
O               Site Name:
                 Type of facility:
                 Q  Manhole              D  Treatment plant               D  Pump station
                 D  Catch basin            D  Collection main               D  Building drain
                 D  Other:	
                 Address:	
                 Additional site information:
     A2-2                           Wastewater Response Protocol Toolbox

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Additional Information
        Has there been a breach of security at the suspected site?                  D Yes          D No
           // "Yes, " review the completed 'Security Incident Report'
        Are there any witness accounts of the suspected incident?                  D Yes          D No
           // "Yes, " review the completed 'Witness Account Report'
        Was the threat made verbally over the phone?                            D Yes          D No
           // "Yes, " review the completed 'Phone Threat Report'
        Was a written threat received?                                           D Yes          D No
           // "Yes, " review the completed 'Security Incident Report'
        Are there unusual wastewater chemical data or public complaints?          D Yes          D No
        Are there unusual symptoms or disease in the population?                  D Yes          D No
           // "Yes, " review the completed 'Public Health Report'
        Is a 'Site Characterization Report' available?                               D Yes          D No
           // "Yes, " review the completed 'Site Characterization Report' (Module 3)
        Are results of sample analysis available?                                  D Yes          D No
           // "Yes, " review the analytical results report, including appropriate QA/QC data
        Is a 'Contamination Identification Report' available?                        D Yes          D No
           // "Yes, " review the completed 'Contaminant Characterization and Transport Worksheet' (Module 5)
        Is there relevant information available from external resources?            D Yes          D No
           Check all that apply
           d   Local law enforcement      d   FBI                          d  Primacy agency
           Ll   Public health agency        D   Hospitals/911 call centers    D  US EPA/Water ISAC
           D   Media reports              d   Homeland Security alerts     d  Neighboring utilities
           HI   WARNs                   D  Other:	
                                                                                                                 CD
        Point of contact:	
                                                                                                                 T3
        	           C
                                                                                                                 CD
        Summary of key information from external sources (provide detail in attachments as necessary):
                                                                                                                 Q_
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          Threat Evaluation

              Has normal activity been investigated as the cause of the threat warning?   D Yes  D No
                  Normal activities to consider
                  D Utility staff inspections             D Routine wastewater sampling
                  n Construction or maintenance       n Contractor activity
                  D Operational changes               D Wastewater chemical changes with a known cause
                  D Other:  	

              Is the threat'possible'?     D Yes         Q No
                  Summarize the basis for this determination:	
                 Response to a 'possible' threat:
                 D None                            D Site characterization       D  Isolation/containment
                 D Increased monitoring/security      D Other: 	
              Is the threat'credible'?     Q Yes         Q No
                 Summarize the basis for this determination:
                 Response to a 'credible' threat:
                 D Sample analysis            D Site characterization  D Isolation/containment
                 n Partial EOC activation       n Public notification    n Law Enforcement Notification
                 D Other:	

              Has a contamination incident been confirmed?     D Yes         D No
                 Summarize the basis for this determination:
                 Response to a confirmed incident:
                  D Sample analysis            D Site characterization D Isolation/containment
O
                  n Full EOC activation          n Public notification   n Provide alternate sanitary services
                  D Initiate remediation and recovery                 D Law Enforcement Notification
                  D Other:  	
     A2-4                          Wastewater Response Protocol Toolbox

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       How do other organizations characterize the threat?
Organization
D Local law
enforcement
D FBI
D Public health
agency
D Wastewater
permitting
agency
D Other
D Other
Evaluation
D Possible
D Credible
D Confirmed
D Possible
D Credible
D Confirmed
D Possible
D Credible
D Confirmed
D Possible
D Credible
D Confirmed
D Possible
D Credible
D Confirmed
D Possible
D Credible
D Confirmed
Comment






Sign off
       Name of person responsible for threat evaluation:


       Print name:
       Signature:
_Date/Time:
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            3     Security Incident Report Form

            INSTRUCTIONS
            The purpose of this form is to help organize information about a security incident, typically a security
            breach, which may be related to a wastewater contamination threat.  The individual who discovered the
            security incident, such as a security supervisor, the Utility Incident Commander, or another designated
            individual may complete this form. This form is intended to summarize information about a security
            breach that may be relevant to the threat evaluation process.  This form should be completed for each
            location where a security incident was discovered.

            Discovery of Security Incident
                Date/Time security incident discovered: 	
                Name of person who discovered security incident: 	
                Mode of discovery:
                   rj Alarm (building)         fj Alarm (gate/fence)           fj  Alarm (access hatch)
                   D Video surveillance       D Utility staff discovery         D  Citizen discovery
                   D Suspect confession      D Law enforcement discovery
                   D Other:	
                Did anyone observe the security incident as it occurred?          D Yes      D No
                   If "Yes", complete the 'Witness Account Report'

            Site Description
                Site Name: 	
                Type of facility
                       rj  Manhole                rj Treatment plant           rj Pump station
                       n  Catch basin              n Collection main            n Building drain
                       n  Other:	
                Address:	

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                Additional Site Information:	
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                Have the following "normal activities" been investigated as potential causes of the security
                incident?
                D  Alarms with known and  harmless causes     D Utility staff inspections
                n  Routine wastewater sampling               D Construction or maintenance
                D  Contractor activity                         D Other:	
      A3-1                          Wastewater Response Protocol Toolbox

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       Was this site recently visited prior to the security incident?             D Yes         D No

          // 'Yes, 'provide additional detail below

          Date and time of previous visit:	
          Name of individual who visited the site:

          Additional information:	
        Has this location been the site of previous security incidents?           D Yes         D No

          \f 'Yes, 'provide additional detail below

          Date and time of most recent security incident:	

          Description of incident:	
          What were the results of the threat evaluation for this incident?

               D 'Possible'           D  'Credible'           D 'Confirmed'

        Have security incidents occurred at other locations recently?           D Yes         D No

          // 'Yes,' complete additional 'Security Incident Reports' for each site

          Name of 1st additional site:	

          Name of 2nd additional site:	

          Name of 3rd additional site:
Security Incident Details

       Was there an alarm(s) associated with the security incident?           D Yes     D No

          // 'Yes,'provide additional information below
                                                                                                          CO
          Are there sequential alarms (e.g., alarm on a gate and a hatch)?      D Yes     D No               QJ
                                                                                                          U
          Date and time of alarm(s):	

          Describe alarm(s):	
                                                                                                          CD-
       Is video surveillance available for the site of the security incident?      Yes            No
                                                                                                         <
          // Yes, provide additional detail below

          Date and time of video surveillance:	

          Describe surveillance:	
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Q_
Q_
                 Unusual equipment found at the site and time of discovery of the security incident:
                    d  Discarded PPE (e.g., gloves and masks)    d  Empty containers (e.g., bottles, drums)
                    D  Tools (e.g., wrenches, bolt cutters)        D  Hardware (e.g., valves, pipe)
                    D  Lab equipment (e.g., beakers, tubing)     D  Pumps or hoses
                    D  None                                  D  Other:	
                    Describe equipment:	


                 Unusual vehicles found at the site and time of discovery of the security incident:
                    D  Car/sedan              D  SUV                    D  Pickup truck
                    D  Flatbed truck            D  Construction vehicle      D  None
                    D  Other: 	
                    Describe vehicles (including make/model/year/color/license plate #, logos, or markings):


                 Signs of tampering at the site and time of discovery of the security incident:
                    d  Cut locks/fences                       d  Open/damaged gates, doors, or windows
                    D  Open/damaged access hatches           D  Missing/damaged equipment
                    D  Facility in disarray                      D  None
                    D  Other: 	
                    Are there signs of sequential intrusion (e.g., locks removed from a gate and hatch)?
                                                                                 D Yes      D No
                    Describe signs of tampering:	
                 Signs of hazard at the site and time of discovery of the security incident:
                    d  Unexplained or unusual odors              d  Unexplained dead animals
                    D  Unexplained dead or stressed vegetation    D  Unexplained liquids
                    D  Unexplained clouds or vapors              D  None
                    D  Other:	
O                  Describe signs of hazard:
          Signoff
                 Name of person responsible for documenting the security incident:
                 Print name:
                 Signature:	Date/Time:
     A3-3                          Wastewater Response Protocol Toolbox

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4     Witness Account Report Form
INSTRUCTIONS
The purpose of this form is to document the observations of a witness to activities that might be
considered an incident warning. The individual interviewing the witness, or potentially the witness,
should complete this form. This may be the Utility Incident Commander or an individual designated by
incident command to perform the interview. If law enforcement is conducting the interview (which may
often be the case),  then this form may serve as a prompt for "utility relevant information " that should be
pursued during the interview.  This form is intended to consolidate the details of the witness account that
may be relevant to the threat evaluation process.  This form should be completed for each witness that is
interviewed.

Basic Information
    Date/Time of Interview: 	
    Name of person interviewing witness: 	
    Witness contact information: 	
       Full Name: 	
       Address: 	
       Daytime phone: 	
       Evening phone:  	
       E-mail address:  	
     Reason the witness was in the vicinity of the suspicious activity:
Witness Account
     Date/Time of activity: 	
     Location of activity:
       Site name: 	
       Type of facility
       D Manhole                D Treatment plant                D Pump station              ~O
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       D Catch basin              D Collection main                 D Building drain               QJ
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       D Other: 	
                                                                                               <
     Address:
    Additional site information:
                      Wastewater Response Protocol Toolbox                        A4-1

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                 Type of activity
                     D  Trespassing
                     D  Theft
                     D  Other: 	
               D  Vandalism
               D  Tampering
                    Additional description of the activity:
  D  Breaking and entering
  D  Surveillance

Q_
Q_
                  Description of suspects

                    Were suspects present at the site?

                    How many suspects were present?
                        DYes
D No
Describe each suspect's appearance:
Suspect #
1
2
3
4
5
6
Sex






Race






Hair Color






Clothing






Voice






                 Were any of the suspects wearing uniforms?

                    If 'Yes/ describe the uniform(s):	
                               DYes
       D No
                    Describe any other unusual characteristics of the suspects:
                    Did any of the suspects notice the witness?

                    If 'Yes/ how did they respond?	
                               DYes
       D No
     A4-2
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Vehicles at the site

  Were vehicles present at the site?            D Yes

  Did the vehicles appear to belong to the suspects?

  How many vehicles were present?	

  Describe each vehicle:
D No

DYes
                                                                         D No
Vehicle #
1
2
3
4
5
6
Type






Color






Make






Model






License Plate






  Were there any logos or distinguishing marks on the vehicles?
  If 'Yes/ describe:	
       DYes
                                                                                D No
   Provide any additional detail about the vehicles and how they were used (if at all):
Equipment at the site
  Was any unusual equipment present at the site?
  d  Explosive or incendiary devices
  D  PPE (e.g., gloves, masks)
  D  Tools (e.g., wrenches, bolt cutters)
  D  Lab equipment (e.g., beakers, tubing)
  D  Other: 	
D Yes
                                                                         D No
                                              d  Firearms
                                              D  Containers (e.g., bottles, drums)
                                              D  Hardware (e.g., valves, pipe, hoses)
                                              D  Pumps and related equipment
   Describe equipment and how it was being used by the suspects (if at all):
                                                                                                         U
                                              Q_
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                  Unusual conditions at the site


                    Were there any unusual conditions at the site?               d Yes         d No


                    D  Explosions or fires             d  Fogs or vapors         d  Unusual odors


                    d  Dead/stressed vegetation      d  Dead animals          d  Unusual noises


                    d  Other:
Describe the site
conditions:



                  Additional observations


                    Describe any additional details from the witness account:
           Signoff


                  Name of interviewer:


                  Print name:
CD
(_)                Signature:	Date/Time:
                  Name of witness:

Q_
                  Print name:
                  Signature:	Date/Time:
     A4-4                          Wastewater Response Protocol Toolbox

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5      Phone Threat Report Form

INSTRUCTIONS
This form is intended to be used by utility staff that regularly answer phone calls from the public (e.g., call
center operators).  The purpose of this form is to help these staff capture as much information as possible
from a threatening phone call while the caller is on the line. It is important that the operator keep the
caller on the line as long as possible in order to collect the information.  Since this form will be used
during the call, it is important that operators become familiar with the content of the form.  The sections
of the form are organized with the information that should be collected during the call at the beginning of
the form (i.e., Basic Call Information and Details of Threat) and information that can be completed
immediately following the call at the end of the form (i.e., the description of the caller).  The information
collected on this form will be critical to the threat evaluation process.

Basic Information
     Name of person receiving the call: 	
     Date phone call received: 	   Time phone call received:

     Time phone call ended: 	   Duration of call: 	
    Originating number: 	   Originating name:
       If the number/name is not displayed on the caller ID, press *57 (or call trace) at the end of the call
       and inform law enforcement that the phone company may have trace information.

     Is the connection clear?     D Yes           D No

     Could the call be from a wireless phone?       D Yes       D No

Details of Threat

     Has the wastewater system already been contaminated?    D Yes       D No

       Date and time of contaminant introduction known?      D Yes       D No

              Date and time if known: 	

     Location of contaminant introduction known?              D Yes       D No

       Site name:
Type of facility
D Manhole D Treatment plant
D Catch basin D Collection main

D Other:

Address:

D Pump station
D Building drain
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    Additional site information:
                    Wastewater Response Protocol Toolbox                        A5-1

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                 Name or type of contaminant known?
                   Type of contaminant
                   D  Chemical                 D  Biological
                   Specific contaminant name/description:	
                                           DYes
D No
                                                         D  Radiological
                 Mode of contaminant introduction known?
                    Method of addition:         D Single dose
                    Amount of material:	
                                                 D Yes          D No
                                                 DOver time      D Other
                   Additional information:
                 Motive for contamination known?           Q Yes          QNo
                 D  Retaliation/revenge            D  Political cause            D  Religious doctrine
                 D  Other:	
                 Describe motivation:	

Q_
Q_
          Caller Information
                 Basic information
                   Stated name: _
                   Affiliation:
                    Phone number:
  Location/address:	
Caller's voice
  Did the voice sound disguised or altered?         D Yes
  Did the call sound like a recording?              D Yes
  Did the voice sound              D Male       D Female
  Did the voice sound familiar?                   D Yes
      If 'Yes/ who did it sound like?	
  Did the caller have an accent?                   D Yes
      If 'Yes/ what did it sound like?	
                                                                                D No
                                                                                D No
                                                                                D Young   D Old
                                                                                D No
                                                                                D No
     A5-2
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How did the caller sound or speak?
D Educated
D Irrational
D Reading a script
What was the caller's tone
D Calm D
D Excited D
D Slow D
D Soft D
D Laughing D
D Deep D
D Other:
d Well spoken
D Obscene
D Other:
of voice?
Angry d Lisping
Nervous D Sincere
Rapid D Normal
Loud D Nasal
Crying D Clear
High D Raspy

D Illiterate
D Incoherent


d Stuttering/broken
D Insincere
D Slurred
D Clearing throat
D Deep breathing
D Cracking

Were there background noises coming from the caller's end?
L~H Silence
D Voices
D Children
D Animals
D Factory sounds
D Office sounds
D Music
D Traffic/street sounds
D Airplanes
D Trains
D Ships or large boats
D Other:
Describe:
Describe:
Describe:
Describe:
Describe:
Describe:
Describe:
Describe:
Describe:
Describe:
Describe:














Signoff
       Name of call recipient:

       Print name:	
       Signature:
       Name of person completing form (if different from call recipient):

       Print name:
_Date/Time:
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 Q_
       Signature:
_Date/Time:
                         Wastewater Response Protocol Toolbox
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Q_
Q_
        6      Written Threat Report Form
        INSTRUCTIONS
        The purpose of this form is to summarize significant information from a written threat received by a wastewater
        utility. This form should be completed by the Utility Incident Commander or an individual designated by
        incident command to evaluate the written threat. The summary information provided in this form is intended to
        support the threat evaluation process; however, the completed form is not a substitute for the complete written
        threat, which may contain additional, significant details.
        The written threat itself (e.g., the note, letter, e-mail message, etc.) may be considered evidence and thus
        should be minimally handled (or not handled at all) and placed into a clean plastic bag to preserve any
        forensic evidence.
        Safety

        A suspicious letter or package could pose a threat in and of itself, so caution should be exercised if
        such packages are received. The US Postal Service has issued guidance when dealing with
        suspicious packages which can be found here: http://about.usps.com/posters/pos84.pdf

        Threat Notification

                Name of  person receiving the written threat: 	
                Person(s) to whom threat was addressed: 	
                Date threat received: 	      Time threat received: 	

                How was the written threat received?

                  D US Postal Service          D Delivery service              D Courier
                  D Fax                     D E-mail                       D Hand-delivered
                  D Other:
                  If mailed, is the return address listed?                D Yes          D No
                  If mailed, what is the date and location of the postmark? 	
to
                  If delivered, what was the service used (list any tracking numbers)?
                  If faxed, what is the number of the sending fax?
                  If e-mailed, what is the e-mail address of the sender?
                  If hand-delivered, who delivered the message?
   A6-1                            Wastewater Response Protocol Toolbox

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Details of Threat
       Has the wastewater system already been contaminated?       D Yes      D No
       Date and time of contaminant introduction known?           D Yes      D No
              Date and time if known:
       Location of contaminant introduction known?
              Site name: 	
                     DYes
         D No
       Type of facility
              D Manhole
              D Catch basin
              D Other:
       Address:  	
e D Treatment plant
asin D Collection main
D Pump station
D Building drain
       Additional site information:
       Name or type of contaminant known?          D Yes
          Type of contaminant
          D Chemical                   D Biological
          Specific contaminant name/description: 	
                       D No
                          D  Radiological
       Mode of contaminant introduction known?
          Method of addition:        D Single dose
          Amount of material:	
          Additional information:	
       Motive for contamination known?
       D Retaliation/revenge
       D Other: 	
               DYes
               D Overtime
       D No
              D other
        DYes
D Political cause
D No
       D  Religious doctrine
       D Describe motivation:

                                                                                                             Q_
                                                                                                             Q_
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           Note Characteristics
                  Perpetrator information:
                    Stated name:	
                    Affiliation:
                    Phone number:
                    Location/address:.
                  Condition of paper/envelope:
                    d  Marked personal
                    D  Neatly typed or written
                    D  Crumpled or wadded up
                    D  Other:	
How was the note prepared?
  D  Handwritten in print
  D  Machine typed
  D  Other:	
Language:
  D  Clear English
  D  Another language:	
  D  Mixed languages:	
Writing style:
  d  Educated
  D  Uneducated
  D  Use of slang
  D  Other:	
Writing tone:
  D  Clear
  D  Cond
  D  Agitated
  D  Other:
               d  Marked confidential
               D  Clean
               D  Soiled/stained
                                                           d Properly addressed
                                                           D Corrected or marked-up
                                                           D Torn/tattered
                                                 D  Handwritten in script       D  Computer typed
                                                 D  Spliced (e.g., from other typed material)
                                                              D  Poor English
                                                 d   Proper grammar
                                                 D   Poor grammar/spelling
                                                 D   Obscene
                                         D   Logical
                                         D   Incoherent
D Direct
;cending D Accusatory
id D Nervous
D Sincere
D Angry
D Irrational

Q_
Q_
           Signoff
                  Name of individual who received the threat:
                  Print name:
                  Signature:
                                   Date/Time:
                  Name of person completing form (if different from written threat recipient):
                  Print name:
                  Signature:.
                                   Date/Time:
     A6-3
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 7      Public Health Information Report Form

 INSTRUCTIONS

 The purpose of this form is to summarize significant information about a public health
episode that could be linked to contaminated wastewater.  This form should be completed by
the Utility Incident Commander or an individual designated by incident command.  The
information compiled in this form is intended to support the threat evaluation process.
 In the case of a threat warning due to a report from public health, it is likely that the public
health agency will assume incident command during the investigation.  The wastewater
utility will likely play a support role during the investigation, specifically to help determine
whether or not wastewater might be the cause.


 PUBLIC HEALTH NOTIFICATION

        Date and Time of notification: 	             	
       Name of person who received the notification:
       Contact information for individual providing the notification

       Full Name: 	
       Title:
       Organization:
       Address:
        Day-time phone:

        Evening phone:
        Fax Number: 	
        E-mail address:
       Why is this person contacting the wastewater utility?
       Has the state or local public health agency been notified?     D Yes          D No

          If "No," the appropriate public health official should be immediately notified.

 DESCRIPTION OF PUBLIC HEALTH EPISODE
       Nature of public health episode:

          D Unusual disease (mild)   D Unusual disease (severe)         D Death
          D Other: 	
                                                                                              Q_
       Symptoms:
D Diarrhea
D Fever
D Other:
D Vomiting/nausea
D Headache
D Flu-like symptoms
D Breathing difficulty
          Describe symptoms:
       Causative Agent: D Known   D Suspected                     D Unknown
                  Wastewater Response Protocol Toolbox                         A7-1

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                 If known or suspected, provide additional detail below

                 D Chemical             D  Biological                 D Radiological

                 Describe 	


                 Estimate of time between exposure and onset of symptoms:  	
              Exposed Individuals:
                 Location where exposure is thought to have occurred
                    D  Residence                D Work                      D  School

                    D  Other: 	

                    Additional notes on location of exposure:  	
                    Collect addresses for specific locations where exposure is thought to have occurred.

               Is the pattern of exposure clustered in a specific area?       D Yes        D  No

               Extent of area
                    D Single building            D Complex (several buildings)   D City block
                    D Neighborhood            D Cluster of neighborhoods     D Large section of city
                    D Other: 	

                    Additional notes on extent of area: 	
                 Do the exposed individuals represent a disproportionate number of:
                    D  Immune compromised       D Elderly                     D  Children
                    D  Infants                    D Pregnant women            D  Women
                    D  Other:
                    D  None, no specific groups dominate the makeup of exposed individuals

          EVALUATION OF LINK TO WASTEWATER
            Were there any public complaints within the affected area?              D Yes        D No

            Were there any unusual wastewater chemical data within the affected area? D Yes       D No
to
Q)          Were there any process upsets or operational changes?                 D Yes        D No
O
            Was there any construction/maintenance within the affected area?       D Yes        D No

            Were there any security incidents within the affected area?              D Yes        D No

Q_
Q_

          SIGNOFF

            Name of person completing form:

               Print name  	
               Signature   	   Date/Time:
     A7-2                         Wastewater Response Protocol Toolbox

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8      Site Characterization Plan Template


INSTRUCTIONS
This form is intended to support the development of a customized site characterization plan developed
in response to a specific wastewater contamination threat. The Incident Commander and Site
Characterization Team Leader should develop this plan jointly if possible. The completed form will be
used to guide site characterization activities in the field. However, it may be necessary to revise the
plan based on initial observations at the site. A form should be completed for each investigation site
that will be characterized.

Threat  Warning Information
Consult Module 2, "Threat Evaluation Worksheet" for details about the threat.

Investigation Site
     Site  Name: 	
    Type of facility:
       D Manhole                    D Treatment plant           D  Pump station
       D Catch basin                  D Collection main            D  Building drain
       D Other:	
    Address:	


    Additional Site Information:
Initial Hazard Assessment
    Are there any indicators of an explosive hazard?         D Yes         D No
       // "Yes," notify law enforcement and do not send a team to the site.
    Initial hazard categorization
       D Low hazard                               D Chemical hazard
       D Radiological hazard                         D Biological hazard                                £O
       // the initial hazard assessment indicates a chemical, radiological, or biological hazard, then only teams
       trained to deal with such hazards should be sent to the site.
                                                                                                    C
 Site Characterization Team
    Name & Affiliation of Site Characterization Team Leader:	
    	           <

    Wastewater utility staff:
       rj Wastewater security specialist     Name:	
       D General security specialist         Name:	
       D Operations specialist              Name:	
       D Other                           Name:	
                         Wastewater Response Protocol Toolbox                        A8-1

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                 Representatives from other agencies:
                   0   Local law enforcement       fj  Fire department
                        us EPA                      FBI
                                       D HazMat
                                       rj Other
             Communication Procedures
                 Mode of communication:
                   [J Phone
                   D Facsimile
              [J 2-way radio
              D Other:
D Digital

Q_
Q_
                 Reporting events:
                   [J Upon arrival at site
                   fj After site evaluation
                   rj Other: 	
              [J During approach
              fj After field testing
[J Site entry
fj Site exit
             Field Screening Checklist for Worker Safety and Rapid Wastewater Testing
./








Parameter1
Radiation
pH /conductivity
Cyanide
Combustible gases
Volatile chemicals
Metals


Screen2
Both Safety and
Wastewater
Wastewater
Wastewater
Both Safety and
Wastewater
Both Safety and
Wastewater
Wastewater


Meter/Kit ID3








Check Date4








Reference
Values








1List the parameters that will be evaluated as part of field screening (examples are listed).
Screening may be conducted for safety, rapid wastewater testing, or both.
3Report the unique identifier for the meter or kit used during screening.
4Report date of last calibration, expiration date, or date of last equipment check as appropriate.
5List any reference value that would trigger a particular action, such as exiting the site.
     A8-2
Wastewater Response Protocol Toolbox

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Sampling Checklist
^














Analyte1
Standard VOCs
Semi-volatiles
Quaternary nitrogen compounds
Cyanide
Carbamate pesticides
Metals/elements
Organometallic compounds
Radionuclides
Non-target VOCs
Non-target organic compounds
Non-target inorganic compounds
Immunoassays
Pathogens- PCR
Water quality - chemistry
No. Samples














Sample Preservation2














1 List the parameters that will be sampled during site characterization (examples are listed).
2 List preservatives and indicate if they are to be added in the field.
Equipment Checklist
 D Completed Site Characterization Plan
 D Emergency Wastewater Sampling Kit (Table 3-1)
 D Reagents (if stored separately)
 D Laboratory grade water (5 gal)
 D Special equipment for the specific site
 D Other:
D  Additional Documentation
D  Field Testing Kit
D  Bags of ice or freezer packs
D  Rinse water (20 liters)
D  Disposable camera
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                        Wastewater Response Protocol Toolbox
                                       A8-3

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            Sample Handling Instructions

                Sample delivery:

                   D  Return samples to wastewater utility

                   D  Ship samples to specified  location


                   D  Deliver samples to specified recipient (e.g., laboratory, law enforcement, shipping co., etc.


                   Name of recipient: 	


                   Phone:  	             Fax: 	


                   Delivery address:  	





                Sample storage and security:


                   Describe any special precautions or instructions related to sample storage and security:
            Signoff




            Incident Commander (or designee responsible for developing Site Characterization Plan):


                 Print Name:  	


                 Signature: 	          Date/Time: 	
            Site Characterization Team Leader:


                 Print Name:
 to
 Q)             Signature:                                          Date/Time:
 o                       	

'-a


 o_
 Q_
      A8-4                          Wastewater Response Protocol Toolbox

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9      Site Characterization  Report Form


INSTRUCTIONS
Members of the Site Characterization Team can use this form to record their observations at the
investigation site.  It also serves as a checklist for notifying incident command at key points during the
characterization. Additional checklists are included in this form for sample collection and exiting the site.
The completed form can also be used as a component of the Site Characterization Report. A form should
be completed for each investigation sited that is characterized.

General Information
     Date: 	      Time arrived at investigation site: 	
     Name of Site Characterization Team Leader: 	
     Phone: 	       Fax:


Location of Investigation Site
     Site Name: 	
    Type of facility:
       D Manhole                    D Treatment plant           D Pump station
       D Catch basin                  D Collection main            D Building drain
       n Other:	
    Address:	
    Weather conditions at site:
    Additional Site Information:
Approach to Site
    Time of approach to site:
     Initial Field Safety Screening (as listed in the "Site Characterization Plan"):                                    ^
       n None                        n Radiation                  n Volatile chemicals
       D HazCat                       D Chemical Weapons          Q Biological agents
       D Other:	   C
                                                                                                       CD
     Report results of field safety screening in Appendix 10 "Field Testing Results Form."
                                                                                                       Q_
     If any field safety screening result is above the corresponding reference value, immediately notify incident      ^

     command and do not proceed further into the site.
                           Wastewater Response Protocol Toolbox                         A9-1

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               Initial Observation and Assessment of Immediate Hazards
                   D  Unauthorized individuals present at the site
                   D  Fire or other obvious hazard
                   D  Signs of a potential explosive hazard (e.g., devices with exposed wires)
                   D  Signs of a potential chemical hazard (e.g., dead animals, unusual fogs, unusual odors)
                   D  Unusual and unexplained equipment at the site
                   D  Other signs of immediate hazard:	
               If there are any indicators of immediate hazard, immediately notify incident command and do
               not proceed further into the site.
               Report initial observations and results to Incident Commander
                         Approval granted to proceed further into the site?      D Yes         D No

          Site Investigation
               Time of Entry to Site:	
               Repeat Field  Safety Screening
                   d  None                    D   Radiation                D  Volatile chemicals
                   d  HazCat                   D   Chemical weapons        D  Biological agents
                   D  Other:	
               Report results of field safety screening in Appendix 10 "Field Testing Results Form."
               If any field safety screening result is above the corresponding reference value, immediately notify
               incident command and do not proceed further into the site.
               Signs of Hazard:
                   d  None                                    d  Unexplained dead animals
                   d  Unexplained dead or stressed vegetation     d  Unexplained clouds or vapors
CO
                   d  Unexplained liquids                        d  Other:	
O
               Describe signs of hazard:
Q_
Q_
     A9-2                          Wastewater Response Protocol Toolbox

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Unexplained or Unusual Odors:
D
D
D
None d Pungent
Sulfur d Skunky
Petroleum D Other:
D Irritating
D Bitter almond

Describe unusual odor:




Unusual Vehicles Found at the Site:
   d  Car/sedan                D  SUV                     D  Pickup truck
   d  Flatbed truck             D  Construction vehicle      D  None
   D  Other:	
  Describe vehicle(s) (include make/model/year/color, license plate #, and logos or markings):


Signs of Tampering:
   d  None                                      d  Cut locks/fences
   d  Open/damaged gates, doors, or windows      d  Open manholes
   d  Missing/damaged equipment                 d  Facility in disarray
   d  Other:	
Signs of sequential intrusion (e.g., locks removed from a gate and hatch)?     d Yes         d No
  Describe signs of tampering:	
Unusual Equipment:
   d  None                                 d  Discarded PPE (e.g., gloves, masks)
   d  Tools (e.g., wrenches, bolt cutters)       d  Hardware (e.g., valves, pipes)
   d  Lab equipment (e.g., beakers, tubing)     d  Pumping equipment
   d  Other:	
   Describe equipment:	
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<
                     Wastewater Response Protocol Toolbox                        A9-3

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Q_
Q_
           Unusual Containers:
              Type of container:
                 D None
                 n Plastic bag
                 n Test tube
                 D Other:	
              Condition of container:
                 n Opened
                 D Unopened
              Size of container: 	
        D Drum/barrel
        n Box/bin
        n Bulk container
D Bottle/jar
n Pressurized cylinder
        n New
        D Old
n Damaged/leaking
D Intact/dry
              Describe labeling on container:
              Describe visible contents of container:

           Rapid Field Testing of Wastewater
                 D None
                 D Cyanide
                 D Pesticides
                 D Other:
        D Residual disinfectant
        D Radiation
        D Biotoxins
D pH/conductivity
D VOCs and SVOCs
D General toxicity
           Report results of rapid field testing in Appendix 10 "Field Testing Results Form."
           If any field test result is above the corresponding reference value, immediately notify incident
           command and wait for instruction regarding how to proceed.
           Report findings of site investigation to Incident Commander.
                  Approval granted to proceed with sample collection?     D Yes       D  No
     A9-4
Wastewater Response Protocol Toolbox

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Sampling
    Time Sampling was Initiated/Completed:	/_
     Implement Sampling Procedures Appropriate for the Hazard Conditions at the Site:
       D Low hazard                                D Chemical hazard
       D Radiological hazard                         D Biological hazard
     // the site is characterized as a chemical, radiological, or biological hazard, then special sampling
     and safety procedures should be followed.
     Safety Checklist:
       D Do not eat, drink, or smoke at the site.
       D Do not taste or smell the wastewater samples.
       D Follow all steps/procedures in HASP.
       D Do use the general PPE included in the emergency wastewater sampling kit.
       D Avoid all contact with the wastewater, and flush  immediately with clean water in the case of
           contact.
       D Slowly fill sample bottles to avoid volatilization and aerosolization.
       D Minimize the time that personnel are on site and collecting samples.
     General Sampling Guidelines:
       D Properly label each sample bottle.
       D Carefully flush sample taps prior to sample collection, if applicable.
       D Collect samples according to method requirements (e.g., without headspace for VOCs).
       D Add preservatives as specified.
       D Carefully close sample containers and verify that  they do not leak.
       D Wipe the outside of sample containers with a mild bleach solution if there was any spillage.
       D Place sample containers into a sealable plastic bag.
                                                                                                     CO
       D Place samples into an appropriate, rigid shipping  container.                                       QJ
                                                                                                     U
       D Pack container with frozen ice packs, as appropriate.
       D Complete "Sample Documentation Form"  (Appendix 11)
       D Complete "Chain of Custody Form" (Appendix 12)
                                                                                                     <<
       D Secure shipping container with custody tape.
       d Comply with any other sample security provisions required by participating agencies.
                          Wastewater Response Protocol Toolbox                         A9-5

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      Exiting the Site
          Time of Site Exit:

Q_
Q_
          Site Exit Checklist:
             n Verify that hatches, locks, etc. are properly secured.
             D Remove all  samples, equipment, and materials from the site.
             D Verify that all samples are in the cooler and properly seal the cooler.
             D Remove all  PPE at site perimeter.
             n Place disposable PPE and other trash into a heavy-duty plastic trash bag.
             D Verify that the perimeter has been properly secured before leaving the site.
             D Ensure that all documentation has been completed before leaving the site perimeter.
             D Comply with any site control measures required by participating agencies.
             n Contact Incident Commander (1C)  and inform the 1C that the team is leaving the site
           Signoff

           Site Characterization Team Leader:
                Print Name: 	

                Signature: 	        Date/Time:
     A9-6                          Wastewater Response Protocol Toolbox

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   10   Field Testing Results Form





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       11   Sample Documentation Form
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Wastewater Response Protocol Toolbox

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12   Chain of Custody Form
Site Name:
Sampler Phone No.:
Sample ID


















Collection Date


















Relinquished by:
Relinquished by:
Relinquished by:
Relinquished by:
Relinquished by:
Sampler:
Signature:
No. Bottles


















Analysis


















Received by: Date/time:
Received by: Date/time:
Received by: Date/time:
Received by: Date/time:
Received by: Date/time:
Dispatched by: Date/time: Received for Laboratory Date/time:
by:
Method of Sample Transport:
Shipper: Phone No.: Tracking No.:
                                                                             .

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                   Wastewater Response Protocol Toolbox
A12

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          13    Contaminant Characterization and Transport Worksheet


          INSTRUCTIONS
          The purpose of this worksheet is to help organize information that will lead to the identification of the
          contaminant to facilitate decisions on appropriate operational responses and provide more accurate
          information for public communication/notification. Contaminant identification will most likely first be a
          presumptive identification followed by more lengthy procedures for verification. While validated analytical
          results are typically the most reliable means of contaminant identification, other information collected
          during the threat evaluation and site characterization may provide valuable insight regarding the identity of
          the contaminant.

          Site Characterization/Threat Evaluation Summary
          Describe the contaminant's odor,  if applicable. (Note: For safety reasons, it is recommended that you not
          intentionally smell samples.)
          What was the physical form of the contaminant?
                 D  Solid                        D  Liquid                     D Gas
                 D  Slurry                       D  Powder                   D Granules
                 D  Other:	
          What color was the contaminant?
          Summarize additional information obtained during site characterization/threat warning that is relevant
          to contaminant identification.
          Summarize the on-line monitoring data, public complaints, or witness accounts that are relevant to
          contaminant identification.
          Describe any other characteristics of the contaminant not mentioned above.
to
          Field Analysis Summary
          Summarize the results of the field analysis for the following parameters:
          Radiation: _
          Chlorine residual: _
          pH conductivity: _
          Cyanide:
          Volatile chemicals:
          Chemical weapons:.
          Biotoxins:
          Pathogens_
          Other:	
     A13-1                         Wastewater Response Protocol Toolbox

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Has death or disease in the population been reported?
Type/symptoms:	
                                 DYes
                       D No   D Unknown
Is there information on unusual sales of pharmaceutical supplies? .
Number of people affected: 	
Number of fatalities: 	
Location/area affected:
Was an epidemiological investigation conducted?
Results:
                               DYes
                       D No   D Unknown
Was a clinical investigation conducted?
Results: 	
                               DYes
                       D No   D Unknown
Is the contaminant acutely toxic and what are the acute effects? DYes
Describe: 	
                                            DNo    D Unknown
Laboratory Analysis Summary
Unusual analytical results:	
Reporting units:	
Analytical method:
Minimum reporting level:
Precision (relative standard deviation):
QA/QC (e.g., recovery of matrix spikes, standard checks, etc.):
Summarize additional information obtained during laboratory analysis that is relevant to
contaminant identification.
Contaminant Characteristics
What is the class of the contaminant?
 D Biological
 D Unknown:
D Chemical
D Radiological

                                                                            Q_
                                                                            Q_
                         Wastewater Response Protocol Toolbox
                                                                   A13-2

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         Can any conclusions regarding the contaminant properties be made? (Place di
         column)
                                              ji idtt


Is the contaminant susceptible to
disinfection or chemical oxidation?
Does the contaminant hydrolyze
into less toxic products?
Does the contaminant hydrolyze
into more toxic products?
Does the contaminant react at
certain pH's?
Is the contaminant water soluble?
Does the contaminant have a
discernable odor or color? (Note:
For safety reasons you should not
intentionally smell samples.)
Is the contaminant volatile or semi-
volatile?
Does the contaminant impact the
pH?
Does the contaminant impact
conductivity?
Does the contaminant impact other
wastewater chemical parameters?
Does the contaminant react with
certain disinfectants (i.e., chlorine,
chloramines, etc.)?
What is the contaminant's half-life?
Yes












No












Unknown












Comment/Additional Information












         Contaminant Public Health Effect Information
         What are the primary routes of exposure?
         D Inhalation           D Dermal contact         D Ingestion
         What are the acute health effects for the exposure routes identified?
                                            D Unknown
Q_
Q_
         What is the contaminant's LD50/ID50 for these routes of exposure?
   A13-3
Wastewater Response Protocol Toolbox

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What is the length of time to first onset of symptoms after exposure?
What are the chronic health effects associated with exposure to the contaminant?
Does the contaminant have the potential for secondary transmission?
D Yes                          D No                          D Unknown
Describe: 	
Is an approach available to prevent undesirable health effects from the contaminant?
D Yes                          D No                           D Unknown
Describe: 	
Are there treatments available for individuals exposed to the contaminant?
D Yes                          D No                          D Unknown
Describe: 	
Are health standards for the contaminant available?
D Yes                          D No                           D Unknown
Describe: 	
By which exposure routes?
D Dermal                D Inhalation              D Ocular                D Ingestion
List the levels for each exposure route.
Access to Contaminant Information (Effects and Properties)
                                                                                                          U
In-house Information
Contact/ phone no.:	
Internal database:
                                                                                                          Q_
                   	     Q_
Public Health Officials
Contact/phone no.:_
Website/database:
                              Wastewater Response Protocol Toolbox                    A13-4

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          Resources
              D  US EPA Water contaminant information tool (WCIT), at http://www.epa.gov/wcit.
              D  US EPA Water Health and Economic Analysis Tool (WHEAT), at
                 http://water.epa.gov/infrastructure/watersecurity/techtools/wheat.cfm
              D  US EPA's List of Drinking Water Contaminants & MCLs:
                 http://www.epa.gov/safewater/mcl.htmltfmcls.
              D  Agency for Toxic Substances and Disease Registry (ATSDR): www.atsdr.cdc.gov.
              D  CDC Emergency Preparedness and Response: www.bt.cdc.gov.
              D  Recognizing Waterborne Disease and the Health Effects of Water Pollution: A Physician On-line
                 Reference Guide: www.waterhealthconnection.org.
              D  Physician Preparedness for Acts of Water Terrorism:
                 www.waterhealthconnection.org/bt/index.asp.
              D  Registry of Toxic Effects of Chemical Substances (RTECS): www.cdc.gov/niosh/rtecs.html.
              D  Risk Assessment Information System (RAIS), which contains information taken from US EPA's
                 Integrated Risk Information System (IRIS), the Health Effects Assessment Summary Tables
                 (HEAST-rad HEAST-nonrad), US EPA Peer Reviewed Toxicity Values (PRTVs) Database, and other
                 information sources: http://www.epa.gov/risk assessment/.
              D  United States Army Medical Research Institute of Infectious Diseases (USAMRIID) Medical
                 Management of Biological Casualties Handbook:
                 http://www.usamriid.army.mil/education/bluebook.html.
              D  WHO: www.who.int/search/en/.
              D  WHO's Public Health Response to Biological and Chemical Weapons (2004):
                 www.who.int/csr/delibepidemics/biochemguide/en/index.html.


          Contaminant Transport
          Summarize what is known regarding the location of contaminant introduction:
to
0        How much material was used:	[Ibs, tons, gals, etc.)
          How was it added?            D Single dose         D Overtime     D   Unknown
          Time period of suspected contaminant introduction:  	
          Elapsed time: 	
     A13-5                        Wastewater Response Protocol Toolbox

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Method of estimating the spread:
D Manual calculations            D Hydraulic model    D Water flow analysis
D GIS                           D Field analysis       D Areas of public complaints
D Areas of people with health-related symptoms
D Other: 	
Estimate the contaminated area: 	
Estimate the population affected:	
Identify any customers with special needs that are within the affected area.
fj Critical Care Facilities
    D Hospitals                                    D Clinics
    D Nursing Homes                               D Dialysis Centers
    D  Other: 	
D Schools
D Day Care Facilities
D Businesses
    D Food and Beverage Manufacturers             D Commercial Ice Manufacturers
    D Restaurants                                  D Agricultural Operations
    D Power Generation Facilities
    D Other:
Signoff                                                                                           ^
                                                                                                   CD
Name of person completing form:	
                                                                                                  ~O
Print name:	
                                                                                                   Q_
Signature:	       Date/Time: 	          ~r
                        Wastewater Response Protocol Toolbox                        A13-6

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            14     Public Health Response Action Worksheet

            INSTRUCTIONS
            The purpose of this form is to help organize information to aid in the evaluation of containment and public
            notification options. The objectives of public health response actions (operational and public notification) are to
            prevent or limit public exposure to potentially contaminated wastewater by either restricting further transport of the
            contaminant through the wastewater system or restricting use of the system through public notification. This
            worksheet assumes that the "Contaminant Characterization and Transport Worksheet" in Appendix 13 has been
            completed to the extent possible.

            Assessment of Public Health Impact
             Identity of the contaminant:          D Suspected         D  Known            D Unknown
             Describe:	
             Contaminant properties (if  known):
                   Route of exposure:
                   D Dermal       D  Inhalation      D  Ingestion     D  Other:	
                   Toxic or infectious dose (LD5o/ID5o) by these routes of exposure:	
                   Symptoms of exposure to high dose:	
                   Symptoms of exposure to low dose:	
                   Other:
            Evaluation of Containment Options
             Describe the location and extent of the contaminated area: _
             Containment options:
             D Valve closures               D Reverse flow conditions       D By-pass
             D Isolate zone(s)
             D Other: 	
             Critical equipment within contaminated area:
             d System equipment            d Zones                     d Pump stations
             D Other:	
             Customers with special needs within contaminated area:
             d Critical Care Facilities
                D Hospitals                                D Clinics
                D Nursing Homes                           D Dialysis Centers
                D Other: _
t^          D Schools
             D Day Care Facilities
             D Businesses
                D Food and Beverage Manufacturers             D Commercial Ice Manufacturers
                D Restaurants                              D Agricultural Operations
                D Power Generation Facilities
                   other:
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Effectiveness of containment options:
D Complete contaminant isolation
D Unknown
D Other:
                D Reduction in spread of contaminant
Is containment expected to provide adequate public health protection?
       D Yes         D No         D Unknown
Timeline for implementation of containment options:
Containment procedures to begin:	
Containment procedures to end:	
Evaluation of Public Notification Options
Is public notification necessary and/or required by any applicable laws or regulations?    D Yes  D No
Collaboration Agencies   (identified in Public Health Response Plan and Utility's ERP)
 D Public health agencies
 D Hospitals/clinics
 D Regional Poison Control Center
 D Other:	
 D Police departments
 D Laboratories
D Fire departments
D Wastewater permitting agency
Type of notification (follow steps shown):
   - Is the contaminant known?                       D Yes    D No
   - Is there a risk of explosion?                       D Yes    D No
                                       If "Yes," consider an evacuation notice.
      Is there a risk of dermal or inhalation exposure?   D Yes    D No       D Unknown
                                               If "Yes" or "Unknown," consider an evacuation notice.
Content of Public Notification
D Has the contamination event been confirmed?
D Is the contaminant known?
D If "Yes," identity of the contaminant:	
D Characteristics of the contaminant:	
D Restrictions on use:	
D Inhalation exposure
D Exposure symptoms:	
D Medical treatments:	
                 D Yes    D No
                 D Yes    D No
D Dermal exposure
                                                                     U
                                                                     '-a
                                                                     Q_
                                                                     Q_
D Transmission mode (if biological):
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             Duration of restriction:
          D Alternate sanitary services:
          D Additional instructions to consumers: _
          D Other information about the incident:
          HI Other:
          Notification to customers with special needs:
          D Critical Care Facilities
              D Hospitals
              D Nursing Homes
              D Other:	
          D Schools
          D Day Care Facilities
          D Businesses
              D Food and Beverage Manufacturers
              D Restaurants
              D Power Generation Facilities
              D Other:	
                                   D Clinics
                                   D Dialysis Centers
                                   D Commercial Ice Manufacturers
                                   D Agricultural Operations
          Are there subpopulations that will be affected at a greater rate than general population?
          D Yes                D No             D Unknown
          Describe:	

Q_
Q_
          Notification to consecutive system:
          D Yes                D No             D Not Applicable
          Method of dissemination (check all that apply):
D     Broadcast media (radio and television)
n     Web site
D     Newspaper
n     Newsletters (wastewater utility/partner)
D     Broadcast phone messages
n     Posting in conspicuous locations
D     Hand delivery
n     Town hall meetings
n     Auto dialer system
D     Other
                            D
                            D
                            D
                            D
                            D
                            D
                            D
                            D
                            D
Government access channels
Listserve email
Letters by mail
Phone banks
Broadcast faxes
Mass distribution through partners
Door-to-door canvassing
Conference calls
Reverse 911
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Notification/restriction timeline:
Notification/restriction to begin:
Notification/restriction to end:	
Alternate Sanitation Services
Are alternate sanitation services needed?             D Yes        D No
Where can customers obtain the alternate sanitary services (e.g., locations for portable toilets)?
Which customers with special needs should be notified of the alternate sanitary services?
D Critical Care Facilities
    D Hospitals                                              D Clinics
    QNursing Homes                                         D Dialysis Centers
    D  Other:	
D Schools
D Day Care Facilities
D Businesses
    D Food and Beverage Manufacturers                        D Commercial Ice Manufacturers
    D Restaurants                                            D Agricultural Operations
    D Power Generation Facilities
    D Other:
Signoff                                                                                                       ^
                                                                                                               CD
Name of person completing form:	
                                                                                                              ^
Print name: 	
                                                                                                               CD
Signature:	      Date/Time: 	                      Q-
                                                                                                               Q_
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          15   Suggested Outline for System Characterization/Feasibility Study
                Work Plan
          I.  Executive Summary
          II. Introduction
          III. System Description and Environmental Setting
          IV. Initial Evaluation and Results of Site Characterization
             A. Contaminants present, volume of wastewater and media affected
             B. Potential pathways of contaminant migration/preliminary assessment of public health and
                environmental impacts
             C. Preliminary identification of candidate response objectives and remedial response action
                alternatives
          V. Work Plan Rationale
             A. Data quality objectives
             B. Work plan approach
          VI. Tasks
             A. Project Planning
             B. Community Relations/Public Communication
             C. Field Investigations
             D. Sample Analysis/Validation
             E. Data Evaluation
             F. Risk Assessment
             G. Evaluation of Remedial Alternatives
             H. Treatability Studies
             I.  Reports
 CJ
• —        VII. Costs and Key Assumptions
          VIII. Schedule
          IX. Project Management
             A. Staffing
             B. Coordination
          X. References
          XI. Appendices
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16   Elements for a Quality Assurance Project Plan
I.  Project Management
   A. Title and Approval Sheet
   B. Table of Contents
   C. Distribution List
   D. Project/Task Organization
   E. Problem Definition and Background
   F. Project/Task Description
   G. Quality Objectives and Criteria
   H.  Special Training/Certifications
   I.  Documentation and Records
II. Data Generation and Acquisition
   A. Sampling Process Design (Experimental Design)
   B. Sampling Methods
   C. Sample Handling and Custody
   D. Analytical Methods
   E. Quality Control
   F. Instrument/Equipment Testing
   G. Inspection and Maintenance
   H. Instrument/Equipment Calibration and Frequency
   I.  Inspection/Acceptance of Supplies and Consumables
   J.  Non-direct Measurements
   K. Data Management
                                                                                        ~O
III. Assessment and Oversight
   A. Assessments and Response Actions
   B. Reports to Management
IV. Data Validation and Usability
   A.     Data   Review,   Verification,   and
   Validation
   B. Verification and Validation Methods
   C. Reconciliation with User Requirements
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Q_
Q_
            17    Elements of a Health and Safety Plan
            I.  The name of a site health and safety officer and the names of key personnel and alternates
               responsible for site safety and health
            II. Health and safety risk analysis for existing site conditions, and for each site task and operation
            III. Employee training assignments
            IV. Description of personal protective equipment to be used by employees for each of the site
               tasks and operations being conducted
            V. Medical surveillance requirements
            VI. Description of the frequency and types of air monitoring, personnel monitoring, and
               environmental sampling techniques and instrumentation to be used
            VII. Site control measures
            VIII. Decontamination procedures
            IX. Standard operating procedures for the site
            X. Contingency plan that meets the requirements of 29 CFR 1910.120(1) (1) and (I) (2)
            XI. Entry procedures for confined spaces
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