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i <br />k WATER SYSTEM INVENTORY REPORT <br />NAME OF SYSTEM: <br />ADDRESS OF SYSTEM: <br />PEOPLE TO CONTACT IN CASE OF AN EMERGENCY: <br />WNPiry <br />(Total Number of Service Connections)SSWS NCWS CLASSIFICATION:sews <br />MARINA TRAILER PARK RESORT FACILITIES SERVED:SCHOOL <br />RESTAURANT RESIDENCES LABOR CAMP MARKET GAS STATION <br />OTHER APARTMENTS INDUSTRY <br />so NO SANITARY WELL SEAL PROPER <br />NO YES PEDESTAL PRESENT: <br />JET CENTRIFUGAL TURBINE PUMP:SUBMERSIBLE <br />NO YES IS DISINFECTION PROVIDED: <br />IF SOURCE IS SURFACE WATER, COMPLETE FOLLOWING: <br />PRETREATMENT (INCLUDES ADDITION OF POLYMER, ROUGHING FILTER):NOYES <br />OTHER CHARCOAL DIATOMACEOUS EARTH FILTER TYPE:SAND <br />GALLONSSTORAGE TANK SIZE: <br />BOTH POST CHLORINATION:PRE <br />NO YES TEST KITS PROVIDED: <br />NO YES CERTIFIED PLANT OPERATOR: <br />NO YES ATTACH APPROVED PLAN FOR SYSTEM: <br />400EH 14 Rev. 2/8231 <br />YES <br />II <br />HEIGHT OF CASING ABOVE GRADE <br /> £ <br />A'D'DRESS/riTY <br />TrnWiroWNIGHT""’ <br />Ckv 4L' <br />DEPTH OF ANNULAR SEAL <br />“-- ------ADDRESS/0177" <br />%£* NW? Zlj <br />TTlEPnONE TWT^TGhT" <br />IF SOURCE IS WELL, COMPLETE FOLLOWING: <br />DEPTH <br />OWNER ’ S REPRES1ENTATIVT <br />DATE: <br />/s''f/t <br />3(/