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If you need help completing this form, please contact Brian Longpre at blongpre@carollo.com or (209) 642-0749
Property Name:
*
Property Address
*
List of potential hazards on site
*
Additives/ Chemicals
Autopsy or Prep. Equipment
Boiler
Booster Pump
Plastic Carbonator
Metal Carbonator
Car Wash
Chemical Storage
Chiller
Cooling tower
Dual service
Food/ Dairy/ Meat processing
Heating & Cooling system (using water)
Minor medical facility
Major medical facility
Metal processing or plating
Multiple Looped Services
Multi-storied building (3+ stories)
Petroleum/ Chemical Processing
Photo development equipment
Pool, Pond, or Fountain
Pressure system
Radioactive process
Recirculating/ Solar system
Recycled water
Sewage ejector/ pump
Submerged inlet
Swimming pool
Water frontage
Water storage
Well or auxiliary supply
None of the above
If you have a device installed, please complete the information below.
Type of device
RP
DC
PVB
Unknown
None
Size:
Serial Number
Manufacturer
Model name/ number
Name of person completing form
Additional Comments or Information
The City of Lodi thanks you for your participation in this survey
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