WASHING OR BATH FACILITES No. of washing - bath facilites Type(s) ( ] sink No. dwelling _ [ ] cub [ J] shower [ ] other, speci Comments WATER SUPPLY Source ( ] rainwater ( ] Commmity system { ] ground water [ ] other, mer ( ] Individual ~ { ] Bot Storage capability of island No. and size of tanks or cisterns Total gallons of capacity If eisterns ~ catchment area Is emergency storage availabie Distribution [{ ] no [ ] piped inside house { ] yes, L1& yes,J capacity [ ] piped outside ( ] other, specify Treatment { ] none ([ ] filter f ] disinfection [ ] good { ] fair ( ]] peor { ] ne (]] yes Comment Sanitary condition Protection from contamination Use ( ] domestic only: { ] domestic plus agriculcure { ] other, specify Comments