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Facility Date <br />Address LEA ID # <br />Service <br />well(s) and /bladder tank(s). The distribution system <br />All past due lab results must be received by: <br />Public Health 9 (8/01)Page 1 of <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 />SMALL WATER SYSTEM <br />OFFICIAL INSPECTION REPORT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 FAX (209) 468-3433 <br />EHD 46-01-001 <br />Revised 8/22/01 <br />________ <br />VfcST Zz <br />Volatile Organic Compounds (VOCs): Required <br /><— t ~ <br />Bacteriological: Required Y^^y/monthly. Continue testing qftVhXVA^. 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 <br />EHD no later than the tenth day of the following month. <br />V Nitrates: Required (f^^fly/annually.______________________________________________________ <br />Nitrites: Requiredy^toffify/once every three years.___________________________________________ <br />Inorganic Chemicals: Required once every three years. The EHD currently waives asbestos and cyanide. <br />once every ^fy^e/six years. <br />Synthetic Organic Compounds (SOCs): DBCP and EDB are required once every three years. <br />Lead and Copper: Required annually/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 />________________________________________________________ <br />Please be aware that failure to conect deficiencies by compliance date will result in staff time charges of $89 per hour. <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 />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 Division (EHD). <br />General Description <br />This system consists of <br />consists of i 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 />Well(s) used for: domestic r industrial irrigation fire standby <br />Treatment: <br />Cross-Connection Control <br />_________________________________ <br />1 ^7tom 6 Sr' <br />hydropneumatic tank(s)/ <br />Type of System