NPDES Permit exceedance (if applicable)

BOD

...........

SS

...........

Ammonia/Nitrogen

...........

Phosphorus

...........

Dechlorination/Toxics

...........

Overflows/Bypasses

...........

Cause of exceedance

Work necessary to correct exceedance

1.

Age of wastewater treatment facilities since last upgrade …. _____years. (0.5 point for each 5 years over 20 years old)...........................................................................

2.

Is plant concrete sound?  Y   N . Extensive spauling of concrete must be evident to be classed unsound.  (0.1 point for each 10% of the concrete thickness that is gone.)....................................................................................................................

3.

If yes, is the reinforcing steel exposed?  Y   N   (1.0 point if steel is exposed.)...

4.

Does the condition of the concrete pose a threat to the integrity of any unit process, building, or mechanical equipment in the plant or pose a safety hazard to operating personnel?  Y   N   (If yes, 1.0 point.)..............................................................

5.

Is the present condition of various plant concrete structures to or causing effluent violations?  Y   N   (If yes, 1.0 point.)..............................................................

6.

Would a failure of any of the concrete structures which are in condition cause a discharge to the waters of the state or an effluent violation?  Y   N   (If yes, 1.0 point.).......................................................................................................................

7.

Is corrosion of metal structures (bridges, walkways, control, valve vaults, handrails, etc.) at the point where a potential threat exists to continued operation of plant units or a safety threat exists for plant personnel?  Y   N   (If yes, 1.0 point.).................

8.

Number of mechanical equipment failures during the past five years…._____. 

Causes:

(0.1 point for each occurrence that resulted in one unit being out of service for at least one day; maximum.)..................................................................................................

9.

Number of mechanical equipment failures during the past year _____. Causes:

10.

Were the mechanical failures in any way related to improper maintenance?.................

Y   N   (If no, then 0.1 point for each event in which a unit process was out of operation for at least one day; 2.0 points maximum.)..................................................

11.

Did any of the mechanical failures result in a raw or partially treated sewage discharge to waters of the state?....Y   N   (If yes, 2.0 points.).........................................

12.

Did any of these mechanical failures result in an actual or potential safety hazard to plant personnel …. Y   N   (If yes, 1.0 point.)..................................................

13.

Are there portions of the plant which are permanently out of service due to mechanical failure or lack of availability of replacement parts due to equipment age?  (0.5 point for each tank or functional unit that is no longer operational, 4 points maximum.).........

14.

Were these mechanical failures due to equipment design or application problems?.... Y   N   (If yes, subtract 1.0 point.)...................................................................

15.

Have all warrantees expired?.... Y   N   (If no, subtract 1 point for each piece of equipment that is not operational for which the warranty is still in effect.).................

TOTAL SCORE, WASTE TREATMENT FACILITIES....................................................

1.

Age of the original sewer system in years. …. _____ (1.0 point for each 10 years or fraction thereof over 50 years old; 3.0 points maximum.)............................................

2.

Material of construction:  vitrified clay pipe (VCP)____; reinforced concrete pipe (RCP) ____; brick ____; cast-in-place concrete ____ (brick = one point; RCP = 0.5 point; cast-in-place = 0.5 point)................................................................................

3.

If concrete, is there crown corrosion?  Y   N   (If yes, 1.0.)..............................

4.

If yes, what percent of the pipe thickness at the crown is gone?....____ (1.0 point for each 25% of pipe thickness lost.)..............................................................................

5.

If pipe is brick, percent of joint material remaining….____ (1.0 point for each 25% of joint material lost.).....................................................................................................

6.

If pipe is reinforced concrete pipe or cast-in-place concrete, is the reinforcing steel exposed?  Y   N   (If steel is exposed, 1.0 point.).............................................

7.

Have there been any cave-ins on the system in the past five years?  Y   N   (If yes, then 1.0 point for each cave-in event; 3.0 points maximum.)................................

8.

Have there been any cave-ins in the past year?  Y   N   (If yes, add one additional point for each event; 3.0 points maximum.).................................................

9.

Have there been any discharges to waters of the state or basement backups as a result of any of these cave-ins?  Y   N   (0.1 additional point for each overflow or basement backup event caused by pipe failures; 3.0 points maximum.).......................

10.

Number of system overflows over the last 5 years due to dry weather surcharging ____ (associated with a non-pipe failure event i.e. tree roots, pipe settled with grit, etc.) (0.1 point for each overflow; 3.0 points maximum.)............................................

11.

Number of homes experience basement backups over the last 5 years due to dry weather surcharging ____ (non-pipe failure event); (0.5 point for each 50 homes or fraction thereof, 5.0 points maximum.).......................................................................

12.

Percent of system that is combined sewers:  ____%  (For sewer separation projects, 1.0 point for each 10% of the entire system or fraction thereof that will be separated by the proposed project; 5.0 points maximum.).........................................................

TOTAL SCORE SEWER COLLECTION SYSTEMS......................................................

1.

Percent of lift stations on the system that are over 20 years old _____ (1.0 point for each 25% of the total stations or fraction thereof over 20 years old; 4.0 points maximum.)................................................................................................................

2.

Are all stations equipped with alarms?  Y   N   (No = 1.0 point.)......................

3.

Number of homes experiencing backups over the lst 5 years due to lift station failures or power outages ____ (1.0 point for each 50 homes or fraction thereof; 4.0 points maximum.)................................................................................................................

4.

Number of homes experiencing backups over the last 5 years due to lift station failures or power outages ____. (1.0 point for each overflow event; 4.0 points maximum.).....

5.

Percent of total station pumping capacity that is out of service due to obsolete equipment ____. (1.0 point for each 10% of total capacity that is out because of inability to get replacement equipment; 2.0 points maximum.).....................................

6.

Do all pumping stations have standby power or alternate means of pumping during power failures as required?  Y   N   (If no, 0.5 point for each station not properly equipped that will be upgraded by this project; 2.0 points maximum.)...........

7.

How many lift stations have equipment or structural deterioration problems which contribute to operational problems or safety hazards to operating personnel? ____. (0.5 point for each station that will have these problems corrected by the proposed project; maximum 2.0 points.)...................................................................................

TOTAL SCORE FOR LIFT STATIONS...........................................................................

Reviewer

Date