HomeMy WebLinkAboutPC-Water_Usage_SurveyCITY OF *
.AUBURN
WASHINGTON
City of Auburn Water Usage Survey
Please mark all of the items that apply to your premises.
YES NO ?
1. Fire Protection System
with chemicals
alternate waters stem
booster
2. Lawn Irrigation System
chemicals
booster
3. Water Cooled Equip.
4. Sewage Tanks or Pumps
5. Chemical Hose Aspirators
6. Laboratory Equip.
7. Swimming Pool or Spa
8. Truck or Tank Filling
9. Industrial Fluid Systems (using H20
10. Steam Generating Equip.
11. Photo Processing Equip.
12. Laundry or Dye Equip.
13. Petroleum Processing
14. Premises where reclaimed and Potable
Water Provided
15. Sand or Gravel Washing
16. Premises with Separate Irrigation System
using the Water Purveyor's Water Supply
with Chemicals
17. Boiler
with chemicals
with feed lines
with circulator
18. Heat Exchanger
double wall
19. Solar Energy System
double wall
20. Livestock Waters
21. Pressure Booster
22. Wastewater Lift Station and Pumping
Stations
23. Steam Table
24. Water Storage Tank (Emergency)
25. Plating Facility
26. Canner Equipment
YES NO ?
27. Temporary Service
28. Reservoirs
29. Car Wash
30. X-ray Equip.
31. Sterilizer
32. Dental Equip.
33. Ice Machine
water cooled
34. Processed Water
with potable water
with make up line
35. Cooling Tower
with make u line
36. Restricted Access
37. Building Over 3 Stories
38. Commercial Laundry/Dry Cleaners
39. Soft Drink Dispenser
40. Hospital, Medical Center Nursing Home,
Veterinary, or Blood & Plasma Center
41. Petroleum Storage
42. Premises with an Unapproved Auxiliary
Water Supply Interconnected with the
Potable Water Supply, i.e., well
43. Soap Injectors
44. Beverage Bottling Plant
45. Chemical Plant
46. Film Processing Facility
47. Laboratory
48. Metal Plating Facility
49. Mortuary
50. Food Processing Facility
51. Petroleum Processing or Storage Plant
52. Piers or Docks
53. Radioactive Material Processing or
Nuclear Plant
54. Agriculture (Farms and Dairies)
55. Survey Access Denied
56. Wastewater Treatment Plant and
Pumping Stations
Please list any other water-using equipment not mentioned above
Owner of Building Tenant of Building
Name: Name:
Company:
Address:
City, State, and Zip:
Phone: FAX:
Company:
Address:
City, State, and Zip:
Phone: FAX:
Please make sure the information provided in this survey is an accurate and current description of the
water system at this address.
Signature of person completing this form Date
REF. H:\Building\HandoutsAuburn Water Survey.doc
Revised 5/2003 AUBURN * MORE THAN YOU IMAGINED