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J <br />D_ .ribution Date <br />No: <br /> Date: <br />Pressure Range: <br />Defects and Remarks: <br />Revised: 12/7/92 <br />System Name: <br />Source of Information! <br />Collected By: <br />State of <br />California <br />Office of <br />Drinking Water <br />Department of <br />Health Services <br />Dead Ends (extent):__________ <br />Growth and sludge In mains: <br />Flushing:_______________ <br />Distance of Mains from Sewers: <br />(Past practice, future policy) <br />Infiltration Hazard:_________ <br />(Relationship to groundwater <br />table, underwater lines, etc.). ’ <br />Disinfection (method): <br />New Mains;____________ <br />After Repairs:__________ <br />Materials: <br />Mains:_________________ <br />Condition:_____________ <br />Lead, copper, brass (extent) <br />Joints <br />rJi <br />aj ______ <br />-C CT - (gcruzvry <br />Cross-Connectlo n <br />and Backflow <br />Prevention: <br />Private Supplies (kind and <br />extent)_____ <br />Cross Connections: <br />With other potable:_______ <br />_____With non-potable;________ <br />Plumbing Code or Regulations: <br />A 1 <br />A i c <br />3> f/ 2> i A r-t £ Tf £— <br />1----------------------------------