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System No:. <br />Date: <br />(3) <br />(4) <br />(5) <br />(6) <br />(7) <br />(8) <br />ODW: 7/92 <br />(D <br />(2) <br />Relation to system <br />Receives from <br />Delivers to <br />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 />Number or Name <br />Date Constructed <br />PurpOSe(storage, sand trap, etc.) <br />Capacity <br />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 />Location: (specific) <br />Controlled Access <br />Distance to Sewep/' <br />Sewage Disposal <br />6etror^. <br />_______31'_________ <br />/era FT <br />A fi FA- <br />a)/A <br />S-jQE. oF TF/^iC. <br />/C17X <br />t^LS, <br />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 />System Name: <br />Source of Information:. <br />Collected by:__ <br />State of California <br />Department of Health Services <br />Reservoir/ /' <br />(Use for all distribution storage, chlorine contact tanks, sarfa traps, etc.)u <br />3 FT- <br />rtF1' <br />/o/A