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System No:. <br />Date: <br />(3) <br />-Pl Ac E- <br />(4) <br />(5) <br />(6) <br />A>4> A>£ <br />(7) <br />(8) <br />ODW: 7/92 <br />(1) <br />(2) <br />Relation to system <br />Receives from <br />Delivers to <br />Number or Name <br />Date Constructed <br />Purpose(storage, sand trap, etc.) <br />Capacity <br />Location: (specific) <br />Controlled Access <br />Distance to Sewe^/ <br />Sewage Disposal <br />•7-4*) fc- <br />A Ffc£T~ <br />Constructlon <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 />f=££7~ <br />ii_________ <br />u <br />$c<i2£- <br />S t/ <br />PAc^Ftc^ A£U-_________ <br />1^73_____________ __ <br />____S'rz- c-A . <br />/rc-G <£«4Cct./v'S Cc y'j1'' <br />zz <br />// <br />/ A. <br />/J/A- <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 .A <br />(Use for all distribution storage, chlorine contact tanks, sarfd traps, etc.) <br />E • £16>+<T^ Ic£ l2-b <br />a c/zX >>c £/\ E-.-J <br />t- F££T <br />Defects and remarks (include <br />statements on cleaning practices, <br />condition o( 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.)