Environmental Protection Agency Region 8 Office of Partnerships & Regulatory Assistance Water Program Attn: Drinking Water Unit (Mail Code: 8P-W-DW) 1595 Wynkoop Street Denver, CO 80202-1129 Business Hours Contact: 1- 800-227-8917 Emergency After-Hours Leave Message at: 303-312-6327 FAX Number: 303-312-6131 Monitoring Plan Template For Stage 1 Disinfectants and Disinfection Byproducts Rule For Small GW PWSs September 2008 This Template is provided by the Environmental Protection Agency in Region 8 for Public Water Systems to use to prepare their Monitoring Plans for the Stage 1 D/DBPR. This document provides guidance to public water systems. The document is not, however, the actual Environmental Protection Agency regulation, nor is it a regulation itself. The actual regulation can be found in 40 CFR (Code of Federal Regulations) Part 141. ------- PWSID# System Name Date of Plan For the Stage 1 Disinfectants and Disinfection Byproducts Rule (D/DBPR), each water system must develop a monitoring plan to show how a system intends to comply with the monitoring requirements of the Rule. The monitoring plan serves as a uniquely tailored roadmap for each specific system to demonstrate that the water quality self-monitoring performed by the system is representative of the water distributed to consumers and is consistent with regulatory requirements. The purpose of this fill able form (template) is to facilitate small water system operators. This form is also available in electronic format. If you like to have this form in electronic format, please email us to forward a copy of the electronic format for your use. This form is available online at: http://www.epa.gov/region8/waterops/ Please call EPA Region 8 if you need further assistance in filling out the form: Harry Jong at 800-227-8917, Ext. 312-7077, or email him at iong.harry@epa.gov: or Mary Wu at Ext. 312-6789, or email her at wu.mary@epa.gov. Please submit your completed Standard Monitoring Plan to: Environmental Protection Agency Region 8 Office of Partnerships & Regulatory Assistance Stage 1 DBPR Rule Manager Mail Code: 8P-W-DW 1595 Wynkoop Street Denver, CO 80202-1129 Monitoring Plan Template—September 2008 T ------- PWSID# System Name Date of Plan Drinking Water Monitoring Plan System Name: PWSID # Monitoring Plan Template—September 2008 7 ------- PWSID# System Name Date of Plan MONITORING PLAN SUMMARY SHEET A. Summary of System Information 1. PWSID Number: 2. System Legal Name: 3. Legal Address: 4. E-mail Address: 5. Legal Contact Name: 6. Legal Contact's Phone Number: 7. Fax Number: 8. System Type: Community I I Non-Transient Non-Community I I 9. Total Population Served: B. Summary of Water Sources Provide a sketch of all source locations in Part II 1. Number of Surface Water Sources: 2. Number of Ground Water Under the Direct Influence of Surface Water Sources: 3. Number of Ground Water Sources: 4. Number of Sources from which your system Purchases Water: C. Summary of Treatment Plants Provide a block process schematic for each plant in Part III 1. Number of Treatment Plants: 2. Number of Treatment Plants Using one or more of the following at any point in the treatment process or for residual maintenance: a. Free Chlorine: b. Chloramines: c. Chlorine Dioxide: d. Ozone: e. Other disinfectant: 3. Do you provide additional treatment to any water purchased from another Public Water System? Yes ~ No ~ D. Summary of Distribution System See schematic map supplied bv EPA in Part IV 1. Does your system supply treated water to other systems? No ~ Yes Q provide details in Part IV If Yes, enter the total population served by these systems: 2. Number of Entry Points to your Distribution System: 3. Number of Routine Microbiological Samples Submitted to EPA per Month: 4. Number of Chlorine Booster Stations in your Distribution System: Signature of Owner or Authorized Representative and Title Date Monitoring Plan Template—September 2008 7 ------- PWSID# System Name Date of Plan PART II - Water Sources Details A. Inventory of Water Sources 1. Untreated Groundwater Sources (Include Purchased Untreated Water Sources) a. Source Name Source ID# (seid) Aquifer Name Type: Permanent (P) Seasonal (S) Emergency (E) P S E P S E P s E P s E PART III - Water Treatment Details A. Treatment Plant Information Treatment Plant Name Treatment Plant ID # Contributing Sources ID # Rated Capacity (MGD, or GPM) Treatment Process Codes List all that Apply* * For complete process codes see Safe Drinking Water Information System (SDWIS) 401 Gaseous Chlorination, Post 403 Gaseous Chlorination, Pre 421 Hypochlorination, Post 423 Hypochlorination, Pre 720 Ultraviolet Radiation B. List all chemicals that are added in each treatment plant ~ Chlorine Gas ~ Sodium Hypochlorite ~ Chloramines ~ UV Monitoring Plan Template—September 2008 4 ------- PWSID# System Name Date of Plan PART IV - Distribution System Details A. Residence Times Determination 1. Provide an explanation of the method(s) used to determine Maximum Distribution System Residence Time 2. Provide an explanation of the method(s) used to determine Average Distribution System Residence Time 3. Provide an explanation of how the distribution system first customer was determined (if applicable). B. Entry Points to the Distribution System 1. Entry Point Designation Description Entry Point Location Name Entry Point Location Identifier Name of the Contributing: Treatment Plants Purchased Sources Untreated Sources 2. Evaluation and description of the extent to which Zones of Influence from each source overlap, if applicable. Monitoring Plan Template—September 2008 5 ------- PWSID# System Name Date of Plan Sketch of Distribution System: Monitoring Plan Template—September 2008 0 ------- PWSID# System Name Date of Plan I. D/DBPR Monitoring Plan Summary i. Table of Treatment Processes Treatment Plant Name Treatment Plant ID # Associated Entry Point Location Identifier Treatment Processes Primary Disinfectant For microbial inactivation Secondary Disinfectant-F or maintaining disinfectant residual Other Oxidants ~ TP01 1 1 Free Chlorine 1 1 Chloramines ~ uv 1 1 Other 1 1 Free Chlorine 1 1 Chloramines 1 1 Free Chlorine 1 1 Chloramines ~ uv 1 1 Other 1 1 Free Chlorine 1 1 Chloramines ii. Summary of Monitoring Records Location and Maintenance Disinfection Byproducts Parameter Records Location Responsible Party Name or Position Phone Number E-mail Address TTHM/HAA5 Maximum Residual Disinfectant Level Parameter Records Location Responsible Party Name or Position Phone Number E-mail Address Total Chlorine Free Chlorine Combined Chlorine Monitoring Plan Template—September 2008 7 ------- PWSID# System Name Date of Plan II. Disinfection Byproducts Monitoring i. Paired TTHM/HAA5 Distribution System Monitoring 1. Complete for each paired TTHM/HAA5 distribution system (DS) sampling site: Sample Site Location Identifier Site Name Site Address Indicate whether this site represents DS maximum or average residence time ~ DS01 1 1 Maximum 1 1 Average 1 1 Maximum 1 1 Average 2. Show the location of each sampling point (by location identifier) on the distribution system sketch in Part IV of your system's monitoring plan. 3. Explain how any monitoring, including that in excess of minimum requirements, will be scheduled so as to be representative of system conditions and how this data will be used to calculate compliance. This explanation should include information about the use of seasonal sources and/or treatment plants and how they will affect the systems TTHM and HAA5 sampling. ii. Disinfection Byproduct Sample Analysis 1. Complete for each analyte tested (EP = entry point, DS = Distribution System): Analyte Frequency (W/M/Q/A) Analytical Method Indicate whether analyst is a Certified Laboratory or EPA Approved Party TTHM 1 1 Certified Laboratory HAA5 1 1 Certified Laboratory 2. Additional Information. (If appropriate to explain system characteristics) Monitoring Plan Template—September 2008 ------- PWSID# System Name Date of Plan III. Maximum Residual Disinfectant Level (MRDL) Monitoring i. For Chlorine or Chloramine Monitoring 1. Complete for each chlorine residual/total coliform sampling site: Site Location Identifier Site Name Site Address 2. Show each sampling site (by location number) on the distribution system map. 3. Additional Information (If appropriate to explain system conditions) a. Disinfectant Residual Sample Analysis i. Complete for each analyte tested (EP = Entry Point, DS = Distribution System): Analyte Frequency (W/M/Q/A) Analytical Method Analysis Performed By: Indicate whether Certified Laboratory or EPA Approved Party Total Chlorine 1 1 Certified Laboratory |_| EPA Approved Party Free Chlorine 1 1 Certified Laboratory |_| EPA Approved Party Combined Chlorine 1 1 Certified Laboratory |_| EPA Approved Party ii. Quality Assurance/Quality Control (QA/QC) - For each analytical test to be performed by a party approved by EPA, other than a certified laboratory, explain the exact QA/QC procedures to be followed to ensure that the analytical result will be accurate and representative of the water being sampled. b. Disinfectant Residual Reporting Please record your chlorine residuals, measured at the same time and same location when you take Coliform (BacT) samples, onto your BacT sampling sheet and ask your laboratory to forward that information to EPA. If your laboratory cannot provide this service to you, use MRDL Form 2 to report quarterly to EPA. Monitoring Plan Template—September 2008 Y ------- PWSID# System Name Date of Plan x (DS01) Max. Residence Time For TTHM/HAA5 EXAMPLE 2: Sketch of Distribution EXAMPLE 1: Schematic of PWS: New Tank. 500,000 Gal. fKTOn c > Chlorinator (TP01) CL Entry Point (SP01) Madison Well #3 (WL03) Monitoring Plan Template—September 2008 TTJ ------- |