Name & Contact Information of Utility Emergency Response Coordinator Deadline for Certifying Risk & Resilience Assessment:

June 30, 2021 if serving 3,301 to 49,999 people.

Name & Contact Information of Backup/Alternate Utility Emergency Response Coordinator Deadline for Certifying Emergency Response Plan:

December 30, 2021 if serving 3,301 to 49,999 people.

Names & Contact Information of All Emergency Response Personnel at the Water/Wastewater System

Plans Should Be in Place for Designating the Following Roles & Defining Appropriate Messages for Each:

Name & Contact Information for Who Will Communicate to Outside Support Agencies

Name & Contact Information for Who Will Communicate to Critical Customers

Name & Contact Information for Who Will Communicate to Media Sources

[See guidance and resource links for communications within the accompanying document: "3-EPA Emergency Response Plan Instructions for CWS"]

Basic System Information

Name of Person(s) Completing This Form:

Title(s) of Person(s) Completing This Form:

Public Water/Wastewater System Name:

Missouri PWSID #/NPDES #:

Physical Address:

System Telephone Number:

System Email Address:

System Website or Social Media Site(s):

Population Served:

Number of Water Connections:

Source Water Type (SW=Surface Water, GW=Ground Water, SWP=SW Purchased, GWP=GW Purchased):

Number of Water Sources:

If Water Is Purchased, Name the Wholesale System(s):

How Many Points of Entry into the Distribution System from Wholesale System(s):

Maximum Daily Water Production (GPD):

If Treating Water, How Many Treatment Plants Are There:

What Types of Chemicals are Used:

If Injecting Chemical(s) at Well House(s), What Chemical(s):

If Using GW, How Many Wells Does System Have:

Deadlines Don't Apply to WW Systems.

Risk and Resilience Assessment & Emergency Response Plan

| |

Emergency Contacts

Chief Water Specialist(s) Name(s) and Telephone Number(s):

Mayor/Board President's Name and Telephone Number(s):

Council/Board Members' Names and Telephone Numbers:

Administrator/Supervisor/Foreman's Name and Telephone Number(s):

Other Staff Members' Names and Telephone Numbers:

Drinking Water Primacy Agency and Telephone Number(s):

Local Health Department Contact Name and Telephone Number(s):

Local Law Enforcement Contact Name and Telephone Number(s):

Local Fire Department Contact Name and Telephone Number(s):

Bulk Water Hauler(s) Contact Name(s) and Telephone Number(s):

Parts Supplier(s) Contact Name(s) and Telephone Number(s):

Chemical Supplier(s) Contact Name(s) and Telephone Number(s):

Media Sources (Television, Radio, Newspaper, Other) Contact Names and Telephone Numbers:

Critical Customers (hospital, health department, government, large water users, essential businesses, organizations serving sensitive populations)

Contact Name(s) & phone number(s)/email address(es)Facility Name

Consider These Asset Categories When Determining Vulnerable Components Potentially Damaged & Resulting Adverse Impacts (below):

Source Water & Intake Water Mains & Wastewater Collection Lines Pre-Treatment, Treatment, & Conveyances

Storage, Distribution Facilities, & Lift Stations Electronic, Computer or Other Automated Systems (including Security of Such Systems & Billing Programs)

Natural Hazards/Emergencies

Flooding

Drought

Winter Storm

Excessive Winds

Pump Failure

Water Main Break

Other

Malevolent Acts Vulnerable Components Cyber Attack

Contamination

Vandalism

Theft

Active Shooter

Identify Hazards and/or Malevolent Acts Most Likely to Occur Estimate Health or Structural Impacts of Each Likely Scenario

Resilience Characteristics of System Components How These Components are Protected from Natural/Human Disaster

Source Water(s) - River(s), Lake(s), Impoundment(s), Well(s):

Intake Structure(s), if SW Source(s):

Interconnection(s) with Wholesale System(s):

Water Treatment Plant(s):

Administrative Office:

Parts, Equipment, Tool Storage Facility(ies)

Finished Water Storage Reservoir(s):

Vulnerable Components Most Likely Damage(s)

Most Likely Damage(s)

Resilience Characteristics of System Components - cont. How These Components are Protected from Natural/Human Disaster

Booster Pump Station(s):

Water Mains & Valves

Fire Hydrants & Flush Stations

Commercial & Residential Meters

Internet-Based Control(s) for Remote Monitoring & Operating System

Electronic Billing Program

Other (identify component)

Monitoring Practices (check all with appropriate response: YES meaning it is performed, NO meaning it is NOT performed, or N/A for not applicable)

Physical Surveillance

Remote (camera) Surveillance All "No" responses should be reconsidered as possible actions to implement.

Video Recording of Critical Infrastructure Premises

Neighborhood Watch

Chemical Analysis (such as chlorine tests in system)

Automated Monitoring Systems (SCADA, Analyzers, etc.)

Financial Infrastructure

Emergency Fund Balance (approximate value will do):

Repair & Replacement Fund Balance (approximate value will do):

Other Utility-Specific Financial Reserves (approximate value will do):

Describe How Chemicals (Treatment & Laboratory) are Used, Handled & Stored

(Example: 1-Ton Chlorine Gas Containers used for disinfection, moved into use via hydraulic crane lift, stored behind locked door within gated facility)

Operation & Maintenance of System (check all with appropriate responses: "Yes", "No", or "N/A")

Doors Locked When Leaving Treatment Plant

Doors Locked When Leaving Well(s) Throughout these checklists as you proceed through this document,

Doors Locked When Stowing Heavy Equipment all "No" responses should be reconsidered as possible actions to implement.

Doors Locked When Stowing Tools

Doors Locked When Away from Vehicle(s)

Sensitive Information (system maps, blueprints, access codes, passwords, etc.) is Kept Secure at All Times

Operation & Maintenance of System (check all with appropriate responses: "Yes", "No", or "N/A") - continued

Water Quality Parameters Are Monitored Frequently at Treatment Plant or Well House(s)

Water Quality Parameters Are Monitored at Least Daily in Distribution System

Customer Complaints of Low Pressure or Other Water Quality Issues are Investigated Immediately

Known or Suspected Water Quality or Quantity Problems are Investigated Immediately

Preventive Maintenance is Practiced on Routine Basis

System Failures of Electronic or Automated Controls are Discovered and Addressed Quickly

Budgets Allow for Replacement of Worn and Failing Components

Redundancy Is in Place for Critical Components (High Service or Well Pump(s), Chemical Feed Pump(s), etc.)

Other Measure(s) (identify):

Strategies & Resources to Improve the Resilience of the System (check all with appropriate responses: "Yes", "No", or "N/A")

Source Water Protection Plan Exists

Source Water Protection Plan Committee is Actively Involved in Protection of Drinking Water Resources

Budgets Include Security Upgrades (such as fencing where this is absent, lighting & cameras, alarms, etc.)

Budgets Include Improved Quality Control Measures (such as water analysis equipment, automated monitoring systems, etc.)

Budgets Include Redundancy for Critical Components Where This is Lacking

Asset Inventories of All Components Have Been Completed or Are Being Conducted

Assessments of the Conditions of Each Critical Component Have Been Completed or Are Being Conducted

A Representative Portion of Meters or All Meters Have Been Tested to Determine Their Accuracies

Under-Registering Meters Are Replaced When Found

Water Rates Have Been Evaluated within the Last Two Years and Adjusted, as Necessary

Capital Reserves are Minimally Sufficient to Replace the Single Most Expensive Item in the System, if it Fails

Capital Reserves are Steadily Increasing through Time

Plans & Equipment to Lessen the Impact of a Malevolent Act or a Natural Hazard (check all with appropriate responses: "Yes", "No", or "N/A")

Recent Review of the System's Emergency Operations Plan by All Persons Listed as Emergency Response Personnel at the System

Table Top Exercise Conducted within the Past Year by All Utility Personnel in Conjunction with Local First Responders

Ability of Operations Staff to Override Automated Controls and Operate Critical System Components Manually

Backup Power Generator(s) and Transfer Switch(es) for Quick Activation in the Event of a Power Outage

Portable Field Analyses Kit(s) for Water Quality Sampling (chlorine residual, pH, alkalinity, conductivity, TDS, DO, etc.)

Established Relationships with Local Emergency Responders Who Understand the Critical Role of the Water System During Emergencies

Mutual Aid Agreement with Neighboring Water Systems for Equipment and Personnel Support

Review of Mutual Aid Agreement within the Past Year

Equipment for Moving Portable Backup Power Generators to Critical Installations

Heavy Equipment for Digging up Pipe Lines or Other Uses

Methods for Lessening the Impact of Malevolent Acts or Natural Hazards (check all with appropriate responses: "Yes", "No", or "N/A")

Alternate Source Water within System (such as a backup well or a secondary lake)

Interconnection with Another Water System Which Can Supply Sufficient Water, at Least for a Temporary Period

An Alternate Intake Structure or Influent Line to Temporarily Replace Main Intake

Flood Protection Barriers (such as facilities built on elevated areas, berms surrounding lowland facilities, or other)

Electrical Control Panels and Other Electrical Equipment Installed or Stored Away from Flood-Prone Areas (near floors or wetlands)

Timely Maintenance of All Structures Housing Critical Equipment

Other Method(s) (identify):

Top Priorities for Improving System Resilience or Emergency Response Measures (to Deter, Detect, Delay, Lessen, or Recover from Harm)

Available Guidance and Hyperlinked Resources for Better Understanding of Each Parameter Are Listed in These Electronic Documents:

2-EPA Risk and Resilience Assessment Guidance for Small CWS under AWIA-final

3-EPA Emergency Response Plan Instructions for CWS

Before Certifying, Review the Certification Forms (included with these documents) to Ensure You Have Completed All That You Are Certifying:

4-Certification of Risk & Resilience Assessment (in Compliance with America’s Water Infrastructure Act of 2018)

5-Certification of Emergency Response Plan (in Compliance with America’s Water Infrastructure Act of 2018)

Remember to Certify Both Your Risk & Resilience Assessment and Your Emergency Response Plan. You Can Access the Electronic Transmission

Method, the Email Address, or the Physical Address (depending upon your preference for how to send these forms to EPA) for These

Certifications at the Following Link (Remember to Review These Documents, Update Them as Needed, and Re-Certify Every 5 Years):

https://www.epa.gov/waterresilience/how-certify-your-risk-and-resilience-assessment-or-emergency-response-plan

To Request Existing Vulnerability Assessment, Email WSD-Outreach@epa.gov (use letterhead & Include System Name, PWSID #, Address, & Point of Contact)

It is highly recommended that utility personnel review many of the hyperlinked resources within the two documents listed above at " Available

Guidance and Hyperlinked Resources… " to adequately prepare for unforseen circumstances. These resources, for instance, help the utility locate

contact information for its Local Emergency Planning Committee, develop Public Release Information Templates, and have contingency plans in

place in advance of any natural hazard or malevolent act. The time for planning for an emergency is PRIOR TO an event; not AFTER it has occurred.