HomeMy WebLinkAbout039-590-019 PRED24-0007 PUBLIC WATER SYTSEM SURVEY (002)
PUBLIC WATER SYSTEM SURVEY
System/Facility Name: _________________________________________________________________
Owner Name: ________________________________________________________________________
Owner Phone/Email: ___________________________________________________________________
Please answer all the questions and sign the form below:
1. Is your system supplied water by an outside provider (e.g., a city, a homeowner’s association, or a mutual water company)? ( Yes (No If Yes, whom: ____________________
2. If your facility’s drinking water is not supplied by an outside provider, then what is the drinking water source?
( Well ( Stream, Creek, River, Pond ( Spring ( Other: ____________________________
3. Number of service connections (i.e., houses, buildings, campsites, etc.) that are connected to your water system: ______________
4. Number of yearlong residents your water serves: _____________
The above figure is based on: (Records ( Estimates
5. Total number of employees, students, or other non-residents regularly served more than 6 months of the year: ________________________
6. Do you serve 25 or more people at least 60 days of the year? ( Yes (No
7. Are restrooms open to the public? ( Yes ( No
8. Does the public have access to any drinking water fountains? ( Yes ( No
DISCLOSURE: Be advised that Sections 116725 and 116730 of the California Health and Safety Code (CHSC) state that any person who knowingly makes any false statement on any report or
document submitted for the purpose of compliance with the California Safe Drinking Water Act may be liable for a civil penalty not to exceed five thousand dollars ($5,000) for each
separate violation for each day that violation continues. In addition, the violators may be prosecuted in criminal court and upon conviction, be punished by a fine, of not more than
twenty-five thousand dollars ($25,000) for each day of conviction, be punished by a fine of not more than twenty-five thousand dollars ($25,000) for each day of violation, be imprisoned
in the county jail not to exceed one year, or both fined and imprisoned.
Name (print): ______________________________ Title (print): _______________________________
Signature: _________________________________ Date: ____________________________________