Page 1 of 4 Please complete all required fields! To be eligible, the following nomination must be submitted, along with supporting documentation, by August 1. Be sure to have supporting documentation ready to submit at the end. Want to submit a nomination the old-fashioned way? Download the nomination form. Fields marked with an (*) are required. Section A: General Information Organization(*) Invalid Input Mailing Address(*) Invalid Input City(*) Invalid Input State(*) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa KansasKentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Invalid Input Zip(*) Invalid Input Nominated By Full Name(*) Invalid Input Phone(*) Invalid Input Title(*) Invalid Input Email(*) Invalid Input Alternate Contact(*) Invalid Input Alternate Phone(*) Invalid Input Section B: System Information Average daily flow in millions of gallons(*) Invalid Input Maximum peak daily flow in millions of gallons(*) Invalid Input Total miles of sewer maintained (estimated)(*) Invalid Input Date original collection system was constructed(*) Invalid Input Date of latest collection system improvements(*) Invalid Input Total number of manholes (estimated)(*) Invalid Input Total number of lift stations(*) Invalid Input Number of collection system employees (including supervisor)(*) Invalid Input Total number of collection system employees who are members of KWEA(*) Invalid Input Section C: Award Information Number of personnel with ABC collection systems certification(*) Invalid Input Average number, per employee, of training hours and/or seminars for collection systems personnel(*) Invalid Input Number of reported system overflow discharge(s)(*) Invalid Input Does organization have a comprehensive plan for I&I and capacity issues?(*) Invalid Input Does organization have a collection system maintenance program?(*) Invalid Input Collection system O&M budget in dollars(*) Invalid Input Number of backups that were the responsibility of the municipality(*) Invalid Input Number of man hours lost due to injuries and/or accidents(*) Invalid Input Amount of Systems Inspected Annually: Television(*) Invalid Input length/quantity Lamp(*) Invalid Input length/quantity Smoke (testing)(*) Invalid Input length/quantity Manhole observation/inspection(*) Invalid Input length/quantity Flow monitoring conducted(*) YesNo Invalid Input Corrective Maintenance Used: Rodding/cleaning(*) Invalid Input length/quantity Installation of trenchless technology(*) Invalid Input length/quantity Foaming/root control(*) Invalid Input length/quantity Line replacement/sewer relief(*) Invalid Input length/quantity Manhole adjustments/rehabilitation(*) Invalid Input length/quantity Line repairs(*) Invalid Input length/quantity Lines flushed annually(*) Invalid Input length/quantity Other Invalid Input length/quantity Lift Stations Number of times checked per week(*) Invalid Input Check the items that apply to your lift stations(*) Adequate spare parts inventoryEmergency plans are in place (e.g. back up power supplies, etc.)Routine maintenance program is implemented (e.g. exercising valves, grease bearings, record keeping, etc.)Remote monitoring (e.g. SCADA, telemetry, etc.) Invalid Input Safety Check the safety items that are available and/or apply to your collection system operation(*) Fully body harnessVentilation blowerHazardous gas detectorTripod or lifting deviceSelf-contained breathing apparatusCommunication equipment (e.g. radios, mobile phone)Regular safety meetingsConfined space entry programOther (please explain) Invalid Input Other Invalid Input Supporting Documentation Please provide documentation and supporting information detailing outstanding and significant contribution in wastewater collection. If preferred, you may email your supporting documentation to Alex Darby. Documentation / Supporting Info Invalid Input - Please check your file does not exceed 15MB pdf, jpg, txt, doc, docx, ppt, pptx (max 15MB) (*) Invalid Input
