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STATE OF CAUFORNtA <br /> CEFARTMENT CF HEALTH SE.:RvJCES fl <br /> Reserves: s' raj e- ca-i7it's <br /> (Use for all distnbutlon storage, chlorine eonta, tanks. sa d traps, etc.) <br /> (Z) System Name: Water Storage System No: <br /> (2) Source of Information: 1nt�*+a„r+� ,-ocdTcis <br /> Colleted by r';nsc_k 3rmr,-1I Date: 1011/95 <br /> azrt well <br /> (3) Number or Name <br /> Cate Constructed I <br /> Purpose(stc a a.sand tma, or-) storage <br /> caoac.ty 000 -al.s <br /> I I <br /> (4) Location: (spec:fic) Yvest or uael I <br /> Controlled Access M I <br /> Dtstanca to Sewer// <br /> Sewage ❑isposal I I <br /> (5) Construction <br /> Matenal steel tank I <br /> Sides <br /> F4ocr <br /> Cover or roof nn I I <br /> Type of Intenor Coating none I <br /> Height top of walls above <br /> ground LT <br /> Surface arainage to reservoir <br /> passible? No <br /> Ventilation: `Ione I I <br /> Screening None <br /> I <br /> (6) Inlet and Cutlet Arrangement I I <br /> Inlet- Location <br /> Cistance Above Bottom I <br /> Cutlet: f <br /> Distance from inlet: 21 ' k <br /> Distance above bottom 00ctom <br /> Drain to where: <br /> Cverflow to where I <br /> Sewer or other Hazardous <br /> connection (make sketch) No <br /> Estimated max_ residence fame <br /> (7) Relation to system <br /> Receives from <br /> Delivers to I I <br /> I I <br /> (8) Oefects and remarks y=ude <br /> statements on c+eanrng pmctf--". <br /> ctlndtfan of 5tlt=Lwe- <br /> particularly of roof <br /> dimensions and shaoe of reservo+r <br /> leakage kind 3 fo=ulon of amass <br /> aoening9 proteC•:an against fnseCz 7utls <br /> and rodents.) <br /> COW. 7/92 <br />