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WATER SYSTEM INVENTORY REPORT <br /> DATE: (� ' <br /> NAME OF SYSTEM: <br /> ADDRESS OF SYSTEM: <br /> PEOPLE TO CONTACT IN CASE OF AN EMERGENCY: <br /> W R S I <br /> TELEPHOE- AY I H <br /> OW R S RPR S A IVE ADDRESS/CI Y <br /> TELEPHONE DAY/NIGHT <br /> *TOTAL NUMBER OF SERVICE CONNECTIONS *POPULATION SERVED <br /> CLASSIFICATION: SCWS NCWS SS41S (Total Number of Service Connections) <br /> FACILITIES SERVED: SCHOOL RESORT TRAILER PARK MARINA <br /> MARKET GAS STATION LABOR CAMP RESIDENCES RESTAURANT <br /> APARTMENTS INDUSTRY OTHER <br /> *SOURCE OF SUPPLY: WELL SURFACE 14ATER SYSTEM <br /> IF SOURCE IS WELL, COMPLETE FOLLOWING: <br /> DEPTH DEPTH OF ANNULAR SEAL SANITARY WELL SEAL PROPER YES—NO— <br /> PEDESTAL <br /> ESNOPEDESTAL PRESENT: YES NO HEIGHT OF CASING ABOVE GRADE <br /> PUMP: SUBMERSIBLE TURBINE CENTRIFUGAL—JET— <br /> IS <br /> ENTRIFUGALJETIS DISINFECTION PROVIDED: YES NO <br /> *TYPE OF TREATMENT: NONE FILTRATTOIV_—Cn-ORINATION` IRON, MANGANESE TREATMENT_ <br /> IF SOURCE IS SURFACE WATER, COMPLETE FOLLOWING: <br /> PRETREATMENT (INCLUDES ADDITION OF POLYMER, ROUGHING FILTER) : YES—NO— <br /> FILTER <br /> ESNOFILTER TYPE: SAND DIATOMACEOUS EARTH CHARCOAL OTHER <br /> STORAGE TANK SIZE: GALLONS <br /> CHLORINATION: PRE POST BOTH <br /> TEST KITS PROVIDED: YES NO <br /> CERTIFIED PLANT OPERATOR: YES NO <br /> ATTACH APPROVED PLAN FOR SYSTEM: YES NO <br /> 500 <br /> EH 14 31 Rev. 9/86 <br />