California Standardized Emergency Management System
                           Potable Water Status Report

From County Operational Area:     

Region:                       

Law Mutual Aid Region:  	       Fire Mutual Aid Region:  

1. Event Name:                         2. Event Date: 

3. Overall Status:                     4. As Of: 

5. Areas Affected: 

6. Situation: 

7. POINT OF CONTACT

a. Name:                               b. Phone:

c. Fax Number:                         d. Alternate Number: 

System       |Current Status |Est.    |Population|Mesures Taken |Mutual|Mutual
Name/Number  |               |Outage  |Affected  |to Protect    |Aid   |Aid
             |               |Duration|          |Public Health |Rcvd  |Rcvd
             |               |(Hrs.)  |          |              |Last  |Next  
             |               |        |          |              |24 hrs|24 Hrs
------------------------------------------------------------------------------
1.           |(see A. below) |        |          |(see B. below)|(Yes/ |(Yes/
             |               |        |          |              |No)   |No)    
             |               |        |          |              |      |
             |               |        |          |              |      |
             |               |        |          |              |      |  
Critical Issues/Needs:
------------------------------------------------------------------------------
2.           |(see A. below) |        |          |(see B. below)|(Yes/ |(Yes/
             |               |        |          |              |No)   |No)    
             |               |        |          |              |      |
             |               |        |          |              |      |
             |               |        |          |              |      |  
Critical Issues/Needs:
------------------------------------------------------------------------------
3.           |(see A. below) |        |          |(see B. below)|(Yes/ |(Yes/
             |               |        |          |              |No)   |No)    
             |               |        |          |              |      |
             |               |        |          |              |      |
             |               |        |          |              |      |  
Critical Issues/Needs:
------------------------------------------------------------------------------
4.           |(see A. below) |        |          |(see B. below)|(Yes/ |(Yes/
             |               |        |          |              |No)   |No)    
             |               |        |          |              |      |
             |               |        |          |              |      |
             |               |        |          |              |      |  
Critical Issues/Needs:
------------------------------------------------------------------------------
5.           |(see A. below) |        |          |(see B. below)|(Yes/ |(Yes/
             |               |        |          |              |No)   |No)    
             |               |        |          |              |      |
             |               |        |          |              |      |
             |               |        |          |              |      |  
Critical Issues/Needs:
------------------------------------------------------------------------------
6.           |(see A. below) |        |          |(see B. below)|(Yes/ |(Yes/
             |               |        |          |              |No)   |No)    
             |               |        |          |              |      |
             |               |        |          |              |      |
             |               |        |          |              |      |  
Critical Issues/Needs:
------------------------------------------------------------------------------
7.           |(see A. below) |        |          |(see B. below)|(Yes/ |(Yes/
             |               |        |          |              |No)   |No)    
             |               |        |          |              |      |
             |               |        |          |              |      |
             |               |        |          |              |      |  
Critical Issues/Needs:
------------------------------------------------------------------------------
8.           |(see A. below) |        |          |(see B. below)|(Yes/ |(Yes/
             |               |        |          |              |No)   |No)    
             |               |        |          |              |      |
             |               |        |          |              |      |
             |               |        |          |              |      |  
Critical Issues/Needs:
------------------------------------------------------------------------------
9.           |(see A. below) |        |          |(see B. below)|(Yes/ |(Yes/
             |               |        |          |              |No)   |No)    
             |               |        |          |              |      |
             |               |        |          |              |      |
             |               |        |          |              |      |  
Critical Issues/Needs:
------------------------------------------------------------------------------
10.          |(see A. below) |        |          |(see B. below)|(Yes/ |(Yes/
             |               |        |          |              |No)   |No)    
             |               |        |          |              |      |
             |               |        |          |              |      |
             |               |        |          |              |      |  
Critical Issues/Needs:
------------------------------------------------------------------------------
11.          |(see A. below) |        |          |(see B. below)|(Yes/ |(Yes/
             |               |        |          |              |No)   |No)    
             |               |        |          |              |      |
             |               |        |          |              |      |
             |               |        |          |              |      |  
Critical Issues/Needs:
------------------------------------------------------------------------------
12.          |(see A. below) |        |          |(see B. below)|(Yes/ |(Yes/
             |               |        |          |              |No)   |No)    
             |               |        |          |              |      |
             |               |        |          |              |      |
             |               |        |          |              |      |  
Critical Issues/Needs:
------------------------------------------------------------------------------
13.          |(see A. below) |        |          |(see B. below)|(Yes/ |(Yes/
             |               |        |          |              |No)   |No)    
             |               |        |          |              |      |
             |               |        |          |              |      |
             |               |        |          |              |      |  
Critical Issues/Needs:
------------------------------------------------------------------------------
14.          |(see A. below) |        |          |(see B. below)|(Yes/ |(Yes/
             |               |        |          |              |No)   |No)    
             |               |        |          |              |      |
             |               |        |          |              |      |
             |               |        |          |              |      |  
Critical Issues/Needs:
------------------------------------------------------------------------------
15.          |(see A. below) |        |          |(see B. below)|(Yes/ |(Yes/
             |               |        |          |              |No)   |No)    
             |               |        |          |              |      |
             |               |        |          |              |      |
             |               |        |          |              |      |  
Critical Issues/Needs:
------------------------------------------------------------------------------
16.          |(see A. below) |        |          |(see B. below)|(Yes/ |(Yes/
             |               |        |          |              |No)   |No)    
             |               |        |          |              |      |
             |               |        |          |              |      |
             |               |        |          |              |      |  
Critical Issues/Needs:
------------------------------------------------------------------------------

Totals:

Total No.               Total No. of              Total
of Systems: 0           Outage Hours: 0           Population: 0              

Created by:                         on: (date/time)

Last Modified by:                   on: (date/time)

DELETE FROM THIS LINE ON AFTER COMPLETING FORM--------------------------------

A. Current Status Block -               B. Measure Taken Block -
   1. System Wide                          1. Boil Water Notice
   2. Source Outage                        2. Source Closure Notice
   3. Source Contaminated                  3. Alternate Supply Order
   4. Distribution System Outage           4. Disinfection Order
   5. Distribution System Contaminated     5. Emergency Notification Required
   6. Power Outage                         6. Public Notification Required
   7. Operating off of Storage             7. User Defined
   8. Returned to Full Service
   9. User Defined