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SAN JOAQI *dUNTY ENVIRONMENTAL HEALTI../EPARTMENT <br /> 304 East Weber Ave, 3rd Floor Stockton, CA 95202-2708 <br /> Phone: (209)468-3420 Fax: (209)468-3433 Web: GVW%V.SJCEHD.COM <br /> SMALL PUBLIC WATER SYSTEM PROGRAM OFFICIAL INSPECTION REPORT <br /> Facility Name: S I /� Date: <br /> Address: b d PWS ID <br /> Type of System: R.E.H.S : WA0_ <br /> 6 r7 <br /> Type of Service: A U / Received By. 0.Phone: <br /> GENERAL DESCRIPTION <br /> This system consists of�_well(s)and hydro pneumatic tank(s)_bladder tank(s). The distribution system <br /> consists of service connections serving a population of Z5;' residents/emplovees'customers/students. General land use in <br /> the surrounding area consists of agricultural,residential,commercial,industrial,rural,pristine,Livestock enclosures. <br /> WELL(s)USED FOR: DOMESTIC — INDUSTRIAL IRRIGATION FIRE _STANDBY <br /> Treatment:NA o F� <br /> CROSS-CONNECTION CONTROL <br /> ❑ Cross-Connection Control Survey ❑ Double Check Valve Assemblies(DCVA) <br /> ❑ Atmospheric Vacuum Breakers(AVB) ❑ Reduced Pressure Principle Assemblies <br /> -Pressure Vacuum Breakers(PVB) r GF ❑ Other backflow prevention devices <br /> All testable backflow prevention devices are required to be tested by a State certified tester annually and immediately <br /> after any installation or repair and the results submitted to the Environmental Health Department(EHD). <br /> Mon( Yp l� roP" e U hY)iYI <br /> 10 FCA -o to <br /> Title 22 of the California Code of Regulations requires routine monitoring of your water system by a State certified laboratory. Sampling <br /> must be performed by State certified laboratory personnel. All samples shall betaken at the wellhead,except for bacteriological sampling. <br /> The EHD strongly recommends the use of non-threaded,dedicated sample taps for bacteriological sampling in the distribution system <br /> Bacteriological: Required monthly. Continue testing monthly unless a sample tests positive for coliform. After a <br /> positive, four repeats must be taken within 24 hours of being notified by your Laboratory and five routine samples shall be taken the <br /> following month. Please be aware that the bacteriological results collected for a system in a calendar month shall be reported to the EHD no <br /> later than the tenth day of the following month. <br /> l Nitrates: Required annuall Q eCr / <br /> vn <br /> Nitrites: Requirecjggwleonce every three years. <br /> 03 Inorganic Chemicals: Required once every three years. The EHD currently waives asbestos and cyanide. <br /> /f a; Volatile Organic Compounds VOCs : Re uired once eve three/six years. <br /> M I aylOs Synthetic Organic Compounds SOCs : EDB are required once eve three ears. .LSC 06h <br /> Lead and Copper: Required /once every three years. One complete sample set is to be taken between <br /> 2(� the months of June through Se [ember. <br /> Secondar Aesthetics): General Mineral and General Physical are due every 3 years. <br /> Radiological: Required every four years if compliance is met by conducting four consecutive calendar <br /> quarterly samples. <br /> Submit a copy of this form with all past due sample res Its . <br /> All past due lab results must be received by: /a/d V Compliance date for all deficiencies: 6 <br /> PLEASE BE AWARE THAT FAILURE TO CORRECT DEFICIENCIES BY COMPLIANCE DATE WILL RESULT IN STAFF TIME CHARGES,OFXS PER HOUR. <br /> EHD 460"01 Page 1 of L smS Offi-dQal(/a577.ion Report <br /> Revised 02/21/03 <br />