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STATE OF CALIFORNIA <br />DEPARTMENT OF HEALTH SERVICES <br />Reservoir/s,Z�4,e"7%- /2�IS <br />(Use for all distribution storage, chlorine contact tanks, sand traps, etc.)-) <br />(1) System Name: fr-e,lC/1 ,."I 4/' � /� ('. i,; System No: <br />(2) Source of Information: <br />Collected by: P, f 6eyA Date: _ 3/ S -/q-/ <br />(3) Number or Name <br />Date Constructed <br />Purpose(storage, sand trap, etc.) <br />Capacity <br />(4) Location: (specific) <br />Controlled Access <br />Distance to Sewer <br />Sewage Disposal <br />(5) Construction <br />Material <br />Sides <br />Floor <br />Cover or roof <br />Type of Interior Coating <br />Height top of walls above <br />ground <br />Surface drainage to reservoir <br />possible? <br />Ventilation: <br />Screening <br />(6) Inlet and Outlet Arrangement <br />Inlet: Location <br />Distance Above Bottom <br />Outlet: <br />Distance from inlet: <br />Distance above bottom <br />Drain to where: <br />Overflow to where <br />Sewer or other hazardous <br />connection (make sketch) <br />Estimated max. residence time <br />(7) Relation to system <br />Receives from <br />Delivers to <br />(8) Defects and remarks (include <br />statements on cleaning practices, <br />condition of structure - particularly of roof, <br />dimensions and shape of reservoir, <br />leakage, kind & location of access <br />openings, protection against insects, birds <br />and rodents.) <br />ODW: 7/92 <br />