Appendix A – Forms

Water Audit Questionnaire for Federal Facilities

Contact:	Phone:
Section:
Area:
Description of operation:
Age of operation and expected useful life:
Quantity of water used (estimate if metered values unavailable):
Daily pattern of water usage (e.g. constant, periodic):
Seasonal use variations:
Location of supply lines (to be drawn on floor plan, include hot, cold, other):
Quantity discharged to sanitary sewer (estimate if metered values unavailable):
Quality of water discharged to sanitary sewer (suspected contaminants and levels):
Quantity (or portion) of water used that is discharged to storm sewer estimate if metered values unavailable):
Quality of water discharged to storm sewer (suspected contaminants and levels):
Quantity (or portion) of water consumed in operation (i.e. does not reach sewer - estimate if metered values unavailable):
Have any reduction/reuse/recycle measures been implemented? Describe:
Possible reduction/reuse/recycle measures for this operation:
Comments re: historical operating problems identified (i.e. leaks, inaccurate metering maintenance, etc.):

Month:	Year:
Meter Location/Identification:	Flow meter units:

						Sample: 1500 hrs 38567
Please enter date, the time and reading for each. When month completed forward promptly.

FROM

Name:

Fax No.:

Tel. No.:

NOTES (enter unusual event description or other remarks below):

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