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_Deloa_t,�Health Services <br /> State of California—Health and Welfla a Agency WATER SYSTEM INSPECTION REPORT _ <br /> J• ~ r DATE <br /> NAME � 1 <br /> RECHECK DATE <br /> LOCATION i t <br /> I COMPUTER NUMBER <br /> MAILING ADDRESS <br /> AIME IN <br /> OWNERIOPERATOR <br /> SERVICE r` Lam„ TIME OUT <br /> PROGRAMI£LEMENT f <br /> 4 MAJOR MINOR The marked items represent HeAlth Code violations and itst be cor- <br /> 1 rected as fia1lo+vs --- <br /> FA <br /> e - •:_.. i <br /> y 2; 3 ng _4 5-ruction 6: 7 ,on = �_ ..8 9 <br /> ection 10:ion 11 12ent Other 13 14' j 3 <br /> Storage i15; 16 r" N <br /> h¢ Piping 17 18 �_ t <br /> oa Cross-Con.Problem <br /> Equip. Mainz. I 20 114L <br /> - <br /> Lu <br /> Records 22. <br /> 0 No Operator 23Z- 4`I_` `, <br /> _! k <br /> Cross-Con Program 125 ` 26 ;? Z <br /> Number of Samples Insuif G4 Samp. 27 <br /> Q ( V <br /> CJ Number of Samples Insult.!-8 Samp. 28 — <br /> O NumberofSamples Insult >8 Samp. 29 <br /> O <br /> O Std- Not Met For<4 Mo-I _30i ~� <br /> LU Std. Not Met For 4-8 Mo. J Y 31 <br /> mSid. Not Met For>8 Mo. �1 32 <br /> Pub. Notification Batt. 33 <br /> Inorg. Insult- C= 34 I ry <br /> Inorg. Sid, Not Met Nitra a 351 <br /> 4 Inorg. Std. Not Met SeieniuLm_•L� 36 <br /> minorg.Sid. Not Met Fluoridew 37 — <br /> � rn <br /> Inorg. Std. Not Met Mef,LR 38 1 <br /> Z 2 <br /> a X Inorg. Std. Not Met Arsenics 39 r <br /> 2 r Inorg- Std. Not Met Other 40 _. _ l i <br /> rn < Pub. Notification Inorg 41 FEE 1�11 4 <br /> Org- Insult. 42cc <br /> 1 <br /> a- Org.Std. Not Met Required 43 I <br /> Org.Std.Not Met Other 44 1, ;, I i <br /> Pub. Notification Org. 45 Z � <br /> Seed. Chem. Insult. ,46 ti —� <br /> o <br /> Seed. Chem, Std- Not Met 47+' �� <br /> U) Consumer Acceptance Not Mel <br /> Ib. Insult- Chronic ^?: <br /> Turb. Insufi. Interm. t50 <br /> Turb. Std. Not Met=nterm. 51 J <br /> ~ Turb.Std, Not Metfr.hronic 52 <br /> Pub. Notification Tuurb. 53 <br /> Permit None Valid 54 <br /> Source 55 <br /> a Storage 56 OFFICE ADDRESS AND PHONE NUMBER RECEIVED 8Y: <br /> O Distribution 57 SANITARIAN: <br /> Safety Inadequate 58 <br /> SYSTEM STATUS:(MARK ONE) <br /> 59 60 61 <br /> MAJOR ❑ MINOR ❑ NO ❑ f PAGE OF <br /> DEF. DEF. DEF. <br /> Third Copy— File <br /> DHS 8092 (5/84) Second Copy—Owner d <br />