Form Center

2. If you need help completing this form, please contact Brian Longpre at blongpre@carollo.com or (209) 642-0749
4. Property Name:*
6. Property Address*
8. List of potential hazards on site*

   1. Additives/ Chemicals
   2. Autopsy or Prep. Equipment
   3. Boiler
   4. Booster Pump
   5. Plastic Carbonator
   6. Metal Carbonator
   7. Car Wash
   8. Chemical Storage
   9. Chiller
   10. Cooling tower
   11. Dual service

   1. Food/ Dairy/ Meat processing
   2. Heating & Cooling system (using water)
   3. Minor medical facility
   4. Major medical facility
   5. Metal processing or plating
   6. Multiple Looped Services
   7. Multi-storied building (3+ stories)
   8. Petroleum/ Chemical Processing
   9. Photo development equipment
   10. Pool, Pond, or Fountain
   11. Pressure system

   1. Radioactive process
   2. Recirculating/ Solar system
   3. Recycled water
   4. Sewage ejector/ pump
   5. Submerged inlet
   6. Swimming pool
   7. Water frontage
   8. Water storage
   9. Well or auxiliary supply
   10. None of the above
10. If you have a device installed, please complete the information below.
12. Type of device

    1. RP
    2. DC
    3. PVB
    4. Unknown
    5. None
13. Size:
14. Serial Number
17. Manufacturer
18. Model name/ number
20. Name of person completing form
22. Additional Comments or Information
24. The City of Lodi thanks you for your participation in this survey
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit Submit and Print

* indicates a required field