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40 <br /> Water System Name: Country Manor MHP Quality Service,Inc. <br /> Month: rtb Year:pc�,t2 Operator: Date System Checked: ayr(o/lD` <br /> A)Well & Distribution LTJ c-. <br /> 1) Visual Inspection: <br /> OK Problem <br /> • Leaks <br /> • Vandalism � <br /> • Weeds EirEi— <br /> • Security 0/ ElEl <br /> Note Any Problems: <br /> 2)Well Casing: OK Problem <br /> • Casing & Seal Condition (Rust) P 11 <br /> • Cracks or Holes in Casing E3,- El <br /> • Well Seal <br /> • Well Seal Bolts Tight Er 0 <br /> El• Casing Vent in Place & Screened [- <br /> • Cement Slab (Cracks, Breaks, Etc.) <br /> Note Any Problems: <br /> 3) Pump and Components: OK Problem <br /> • PSI Correct � <br /> • Pipe Fitting Tight <br /> • Check Valve Leaking <br /> • Pressure Switch Condition [� El <br /> El <br /> • Electrical Control Box Sealed [� <br /> • Electrical Junction Box Sealed Or ❑ <br /> • Electrical Conduit Condition ❑ <br /> • If Discharge Valve, Insure It's Open <br /> • Sample Tap Condition <br /> Note Any Problem: <br /> 4) Pressure Tank: OK Problem <br /> Hydro System <br /> • Leaks, Rusting, Damage ❑ <br /> • Water Logged or Air Logged [a <br /> • Air Release Valve Operating [a <br /> • All Valves Open <br /> • Tank Support Sound ET <br /> Note Any Problem: <br /> 5) Distribution System OK Problem <br /> • All Sample Site E21 M <br /> • ID Tags on Sample Sites &Well El 19, <br /> • Any Leaks 0 [3, -h, <br /> • Backflow Condition <br /> Note Any Problem: , c�a \zp. <br /> Pressure Settings: On: LAO Off: 00 <br /> Quality Service,Inc. System Check Sheet <br /> County Manor MHP Water System <br /> IYJ.tcXCS...� : k C7C \ <br />