Facility Information

Facility Name

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Facility Address

Street Address

County

Please select a county. Adair Alfalfa Atoka Beaver Beckham Blaine Bryan Caddo Canadian Carter Cherokee Choctaw Cimarron Cleveland Coal Comanche Cotton Craig Creek Custer Delaware Dewey Ellis Garfield Garvin Grady Grant Greer Harmon Harper Haskell Hughes Jackson Jefferson Johnston Kay Kingfisher Kiowa Latimer LeFlore Lincoln Logan Love Major Marshall Mayes McClain McCurtain McIntosh Murray Muskogee Noble Nowata Okfuskee Oklahoma Okmulgee Osage Ottawa Pawnee Payne Pittsburg Pontotoc Pottawatomie Pushmataha Roger Mills Rogers Seminole Sequoyah Stephens Texas Tillman Tulsa Wagoner Washington Washita Woods Woodward

City

Zip Code

Individual Project Officer Name

Date

Format: MM/DD/YYYY

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Background Information

Please answer these questions about your facility to the best of your abilities.

What year was the original building constructed?

Have any buildings or additions been added to the original facility?

Yes No

Are blueprints of the building available?

Yes

No

What materials is the service connection line made of and where is it located?

Does the facility have a filter maintenance and operation program?

Yes

No

Is there a point of entry or point of use treatment in use?

Yes

No

If yes, what type?

List known plumbing dead ends, low use areas, existing leaks, or other problem areas.

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Facility Interior Plumbing 

What are the interior plumbing water pipes made of?

lead

plastic (PVC)

galvanized metal

cast iron

copper

other

unknown

How does water flow through the building: which areas receive water first and which areas receive water last?

Are brass fillings, faucets, or valves in your facility?

Yes

No

If yes, where?

Note specifics in the Outlet Inventory form during the initial walkthrough.

Are there any outlets that are not operational and therefore out of service permanently or temporarily?

Yes

No

Are there any outlets shut off for COVID that have not returned to service?

Yes

No

Will these outlets return to service at any point in the future?

Yes

No

Are there any complaints about taste or odor of drinking water in the facility?

Yes

No

Are there any renovations planned for any of the plumbing system?

Yes

No

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