Page 1 of 3 Please complete all required fields! To be eligible, the following questionnaire must be completed in its entirety and submitted by August 1. You may have an unannounced visit by one or more of the members of the KWEA Safety Committee. Fields marked with an (*) are required. Section A: General Information Category(*) Please SelectCategory A: Less than 1.0 MGD Treatment FacilityCategory B: 1.0-5.0 MGD Treatment FacilityCategory C: Greater than 5.0 MGD Treatment FacilityCategory D: Industrial Treatment Facility Invalid Input Name of Community or Industry(*) 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 Name of Treatment Facility(*) Invalid Input Approximate Location of Facility(*) Invalid Input Facility 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 Facility NPDES Permit No.(*) Invalid Input Submitted By Full Name(*) Invalid Input Phone(*) Invalid Input Email(*) Invalid Input Section B: Process Information Design Capacity of Facility (MGD)(*) Invalid Input Check all applicable unit processes included in facility operation(*) Facilities LagoonAerated LagoonInfluent Pump StationBar ScreenComminutorGrit RemovalPrimary ClarifierRBCTrickling FilterActivated SludgeExtended AerationPure OxygenAerobic Sludge DigestionAnaerobic Sludge DigestionSand FiltrationChemical TreatmentVacuum FiltrationCentrifugeBelt Filter PressIncinerationDisinfection - ChlorineDisinfection - OzoneDisinfection - UVDisinfection - Other (Please describe)Other (Please describe) Invalid Input Disinfection - Other (Please describe) Invalid Input Other Unit Process(es) Invalid Input Number of full-time operations personnel assigned to your facility(*) Invalid Input What percent of certified personnel is assigned to your facility?(*) Invalid Input Section C: Safety Information Does your organization have an active safety program?(*) YesNo Invalid Input Please provide a general description of your program. Invalid Input Does your wastewater department have a person assigned as a safety coordinator?(*) Please SelectYesNo Invalid Input How many accidents occured in last calendar year at your facility as a result of not using proper safety equipment?(*) Invalid Input How many accidents in the last calendar year resulted in lost time whatsoever?(*) Invalid Input How many man-hours of actual work were lost in the last calendar year due to accidents at your facility?(*) Invalid Input Do you have monthly meetings for the purpose of discussing safety issues at your facility?(*) Please SelectYesNo Invalid Input Do you require pre-employment physical examinations of all personnel?(*) Please SelectYesNo Invalid Input What percent of employees at your facility have received first-aid training within the last three years?(*) Invalid Input (*) Invalid Input
