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Date:Facility Name: <br />Address: <br />R.E.H.S.:Type of System: <br />Phone:Type of Service: <br />1 <br />CROSS-CONNECTION CONTROL <br /> Double Check Valve Assemblies (DCVA) Cross-Connection Control Survey <br />atIVOTtPK>O <br />'Zjoo<3 <br />nj^oS <br />'LoH <br /> Atmospheric Vacuum Breakers (AVB) Reduced Pressure Principle Assemblies <br />^Pressure Vacuum Breakers (PVB) 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 />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 be taken 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 quarterly/monthly. Continue testing quarterly/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 />Nitrates: Required (gytytyAy/annually._______________________________ <br />Nitrites: Required ffipflesly/once every three years. <br />Inorganic Chemicals: Required once every three years. The EHD currently waives asbestos and cyanide. <br />Volatile Organic Compounds (VOCs): Required once every three/six years. <br />Synthetic Organic Compounds (SOCs): DBCP and EDB are required once every three years. <br />Lead and Copper: Required annually/^prOe^^ry-thjetryeaTs? One complete sample set is to be taken between <br />the months of June through September. <br />Secondary (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 results. <br />All past due lab results must be received by: Compliance date for all deficiencies: <br />“^p^^7ir^^R^™^^ui^ETnCORR^^)EFraENaESB^OMPLIANCE DATE WILL RESULT IN STAFF TIME CHARGES OF $89 PER HOUR. <br />EHD 46-014)01 Page 1 of —1— SPWS OffiCial '^P60*'0" ReP°rt <br />Revised 02/21/03 <br />\a€ _ <br />R.E.H.S.: _______________ <br />Received By: <br />San Joaquin unty Environmental Healt Department <br />304 East vVeber Ave, 3rd Floor Stockton, CA 952v2-2708 <br />Phone: (209) 468-3420 Fax: (209) 468-3433 Web: WWW.SJCEHD.COM <br />SMALL PUBLIC WATER SYSTEM PROGRAM OFFICIAL INSPECTION REPORT <br />GENERAL DESCRIPTION Z <br />This system consists of I well(s) and | hydro pneumatic tank(s) r bladder tank(s). The distribution system <br />consists of I service connections serving a population of | 5^ residents/employees/customers/students. General land use in <br />the surrounding area consists of agricultural, residential, commercial, industrial, rural, pristine, livestock enclosures.Well(S) USED for: r DOMESTIC INDUSTRIAL v IRRIGATION FIRE STANDBY <br />T reatment:-------------------------------------- ---- ------------------------ -------------------------------------------------------------------------- <br />PWS ID #: <br />WA#: