REPORT DATE
WATER POINT INSPECTION
For use of this form see TB MED 577; the proponent of this form is the Office of the Surgeon General
TO
FROM
INSPECTION RATING
WATER POINT NO.
MAP COORDINATE LOCATION
OPERATING UNIT
TEAM CHIEF
UNIT REPRESENTATIVE
INSPECTING UNIT
DATE/TIME GROUP
INSPECTED BY
INSPECTION CHECKLIST CRITERIA
YES
NO
1.
SITE CONDITIONS
a.
Adequate Drainage
b.
Dust Control Practiced
c.
Rodent/Insect Control Practiced
2.
BIVOUAC AREA
a.
100 Ft. Away/Downstream
b.
Latrines 100 Yd. Away
c.
Handwashing Devices Present
d.
Garbage Control Practiced
3.
WATER SOURCE
a.
No Pollution Nearer Than 2 Miles
b.
Chemical Agents Present
c.
Radioactivity Present
4.
INTAKE LINE
a.
Intake Strainer Attached
b.
4 In From Surface or Bottom
5.
EFFLUENT LINE
a.
Backwash Water Sump Present
b.
Sludge Sump Present
c.
Discharge 25 Yd. From Intake
6.
ERDLATOR
a.
Trailer/Truck Level
b.
Coagulator Weir Level
c.
D-E Filter Pressure Maintained
d.
Grounding Present
7.
ROWPU
a.
Trailer/Pallets Level
b.
Filter Backwash Tank Full
c.
Grounding Present
d.
Separate Storage Tanks Used for Raw and Brine Waters
8.
a.
Grounding Present
b.
Fire Extinguisher Present
c.
Hearing Protection Used
d.
Sufficient Ventilation
9.
OPERATOR PROTECTION
a.
Rubber Hip Boots Used
b.
Long Rubber Gloves Used
10.
OPERATOR MONITORING
a.
WQAS-E Chemicals Not Expired
b.
Water Source Tested
c.
Treated Water Tested
d.
Chemical Usage Recorded
e.
Gauge/ Meter Readings Recorded
f.
Chlorine Residuals Checked Hourly
DA FORM 5456-R, OCT 85
Figure 2-5. DA Form 5456-R (front).
2-11
QM 4922
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