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Facility <br />Address <br />WA#Type of Systei <br />Phone #Service <br />Cross-Connection Control <br />Public Health 72 (1/02)Page 1 of <br />EHD 46-01-001 <br />Revised 01/25/02 <br />General Description <br />This system consists of <br />consists of l <br /> Cross-connection control survey completed <br /> Atmospheric Vacuum Breakers (AVB) <br /> Pressure Vacuum Breakers (PVB) <br /> Double Check Valve Assemblies (DCVA) <br /> Reduced Pressure Principle Assemblies <br /> Other backflow prevention devices <br />]well(s) and / hydropneumatic tank(s)/ bladder tank(s). The distribution system <br />service connections serving a population of residents/employees/customers/students. General land use <br />in the surrounding area consists of agricultural, residential, commercial, industrial, rural, pristine, livestock enclosures, <br />rWell(s) used for: domestic / industrial irrigation fire standby <br />T reatment:____________________________________________________________________________ <br />SV ',L PUBLIC WATER SYSTEM PRO <br />OFFICIAL INSPECTION REPORT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />304 EAST WEBER AVENUE, 3rd FL, STOCKTON, CA 95202 <br />(209) 468-3420 FAX (209) 468-3433 <br />gg// <br />fat//7 /'/'fc _______ <br />All testable backflow prevention devices are required to be tested by a State certified tester annually and immediately after any <br />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. <br />Sampling must be performed by State certified laboratory personnel. All samples shall be taken at the wellhead, except for <br />bacteriological sampling. The EHD strongly recommends the use of non-threaded, dedicated sample taps for bacteriological sampling <br />in the distribution system. <br />Bacteriological: Required Continue testing q^p^y^onthly^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 <br />EHD no later than the tenth day of the following month. <br />Nitrates: Required^^y^^/annually. <br />Nitrites: Required quarterly/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/^jJ^^yg^Jb^^&^ieftsi One complete sample set is to be taken <br /> between 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: 'Pel Compliance date for all deficiencies:___________________ | <br />Please be aware that failure to correct deficiencies by compliance date will result in staff time charges of $89 per hour. <br />PWS'D‘ <br />y - y?*/-