Clean Watersheds Needs Survey (CWNS) 2012 Gap Approach - Sample Data Request Form

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Asset replacement costs are not requested in any versions of the form. These costs will be calculated in the CWNS DEP based on other data entered in the form
2) Facility Effluent Treatment Level
Present*:
Projected*:
3) Facility Type Choose the appropriate descriptors from the list in Appendix 1 (to be completed later) to complete the columns “Type” and “Planned Changes”. Indicate Whether the facility is “Present” or “Projected” by placing a check mark in the appropriate column(s). Type* Present* Projected* Planned Changes*
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Clean Watersheds Needs Survey (CWNS) 2012 Gap Approach - Sample Data Request Form
(* = Data Filled in from CWNS – facilities would only need to verify this data, updating where relevant) CWNS #: 1) Facility Information
Average User Charge per month __________________________Do NOT enter changes due to inflation. Enter amounts in current Local Fiscal Year dollars)
Total
“Current”
Salaries, wages, benefits Supplies, equipment, chemicals Repairs Utilities Payments to other facilities Funds added to reserves Debt service Miscellaneous Total
June 22, 2010
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Clean Watersheds Needs Survey (CWNS) 2012 Gap Approach - Sample Data Request Form
4) Revenues and Expenses Service Area Zip Code(s)* ______________________________________________
June 22, 2010
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Clean Watersheds Needs Survey (CWNS) 2012 Gap Approach - Sample Data Request Form
5) Asset Inventory In the asset inventory tables in the following 3 pages, the Calculated Failure Years (CFY) is based on information you enter for a given asset. For a particular asset, if you have knowledge that leads you to assess that the asset will fail in a year different than the CFY, enter the year you estimate it will fail in the Predicted Failure Year (PFY) column, otherwise leave this column blank. If you enter a PFY earlier than the CFY, enter one of the following choices in the “Reason for Failure before CFY” column: Capacity – Volume of demand exceeds design capacity (Growth, system expansion,…) Level of Service – Functional requirements exceed design capacity (Permit conditions, noise, odor, service targets,…) Condition – Use of asset reduces performance below an acceptable minimal level (Physical deterioration due to age, usage, acts of nature,…) Efficiency – Performs well, but costs of operation significantly exceed those of feasible alternatives
4) Flow and Population Served Information MGD Existing flow of wastewater treated* Current design capacity* Projected design capacity* No. of residential accounts No. of commercial/industrial accounts Population served* Present Projected in 20 Years
Year
Annual Expenses
(Do NOT enter changes due to inflation. Enter amounts in current Local Fiscal Year dollars)
Salaries, wages, benefits Supplies, equipment, chemicals Repairs Utilities Payments to other facilities Funds added to reserves Debt service Miscellaneous
Type of ownership Facility Name* (public, private, federal)*: The facility is part of the following system*: Organization responsible for facility*: NPDES Permit Number(s)*: Point of Contact Information Authority Name*: Name*: Role / Title*: Address*: City*: State*: Zip Code*: Phone*: Fax*: Email*: Treatment Plants Only - Facility Physical Location (if different from Point of Contact Address) Address*: City*: State*: Zip Code*: Facility Discharge Table This Facility discharges to*: Type of area* CWNS Number* Facility Name* % of Discharge Flow Present* Facilities that discharge to this Facility: Projected* CWNS Facility Number* Facility Name*
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There will be an electronic, editable version of the form (with picklists and calculations coded in). Like the hard copy form, this electronic Gap Approach form will be prepopulated with the most current CWNS data.
The Gap Approach Subcommittee of the CWNS 2012 Workgroup will continue to review and provide input on finalizing this form between now and Fall 2010.
June 22, 2010
Please enter revenues and expenses using the most current Local Fiscal Year data available (labeled “Current” in the below tables)
“Current” Local Fiscal Year ________ First Month of Local Fiscal Year _________________
Optional – Enter Known Future Changes in Revenues
Year
Total retail user charges Total wholesale user charges Interest Funds drawn from reserves Miscellaneous