Site Location: Ammonia: Chlorine: Anhydrous (gas) Gas Ammonium Sulfate (solution) TYPE OF Solution Ammonium Hydroxide (Aqua Ammonia) DISINFECTION: (please explain): # of Feeders/Pumps (2 minimum): FEEDERS/PUMPS: Type: Standby Equipment? Yes No Stored in Areas Not in Direct Sunlight? Yes No GENERAL: Vented to Outside? Yes No Enough for 10 Days Storage? Yes No Chlorine Storage & Feed System Building Separated? Yes No Doors Open Outward? Yes No Shatter-Resistant Inspection Windows? STORAGE OF Yes No Fan/Light Switches Located Outside? CHLORINE GAS: Yes No Air Inlet Near Ceiling? Yes No Vent Fan Near Yes No Cylinders Restrained in Position? Yes No Weighing Scales? Yes No Ammonia Storage & Feed System Building Separated? Yes No STORAGE OF Fan/Light Switches Located Outside? Yes No AMMONIA GAS or Forced ventilation? Yes No AQUA AMMONIA: Shatter-Resistant Inspection Windows? Yes No Leak Detection Systems in all Areas Through Which Ammonia is Piped? Yes No LIFT STATION (S) Project: Engineer: General Scope of Project: PUMPS # per Station:
Site Location: TYPE OF DISINFECTION: Chlorine: Gas Solution Ammonia: Anhydrous (gas) Ammonium Sulfate (solution) Ammonium Hydroxide (Aqua Ammonia) (please explain): FEEDERS/PUMPS: # of Feeders/Pumps (2 minimum): Type: GENERAL: Standby Equipment? Stored in Areas Not in Direct Sunlight? Vented to Outside? Enough for 10 Days Storage? Yes No Yes No Yes No Yes No STORAGE OF CHLORINE GAS: Chlorine Storage & Feed System Building Separated? Doors Open Outward? Shatter-Resistant Inspection Windows? Fan/Light Switches Located Outside? Air Inlet Near Ceiling? Vent Fan Near Cylinders Restrained in Position? Weighing Scales? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No STORAGE OF AMMONIA GAS or AQUA AMMONIA: Ammonia Storage & Feed System Building Separated? Fan/Light Switches Located Outside? Forced ventilation? Shatter-Resistant Inspection Windows? Leak Detection Systems in all Areas Through Which Ammonia is Piped? Yes No Yes No Yes No Yes No Yes No LIFT STATION (S) Project: Engineer: General Scope of Project: PUMPS # per Station:
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