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I <br />Facility <br />Address <br />WA# <br />Service <br />U <br />7 <br />Page 1 of SMALL PUBLIC WATER SYSTEM OIREHD 46-01 <br />10/01/07 <br />) Vor a- <br />For pUASA <br />San Joaquin County <br />Environmental Health Department <br />600 East Main Street, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax: (209) 468-0341 Web: www.sjgov.org/ehd <br />de Check Valve Assemblies (dcva) <br />iced Pressure Principle Assemblies(RP) <br />'ZooS i <br />7.^0^ <br />Type of System. , T <br />lommercial, industrial^rural, <br />. standby <br />certified fester annually and <br />T1Z-+ k4x^ <br />SMALL PUBLIC WATER SYSTEM PROGRAM OFFICIAL INSPECTION REPORT <br />D3te s/ s/ <br />o q i, loS’L <br />Phone # <br />‘2- 3 C>C> <br />^EKS <br />I well(s)( v 1 ) and hydropneumatic/ bladder/ storage tank(s) <br />@ gallons. The distribution system consists of f_ service connections serving a population of residents /employees <br />/customers/students. General land use in the surrounding area consists of/^griculturallQpsidentiaJ. <br />pristine, livestock enclosures. Sources of water for: domestic^ X. industrial^ Qrrigation >4, jfire <br />Trea'ment: Certified Distribution/Treatment Operator (CDO/CTO): -------------------------------- p rp to. <br />Cross-Connection Control: All testable backflow prevention devices are required to be tested by a State cei <br />immediately after any installation or repair and the results submitted to the Environmental Health Department (EHD). <br /> Cross-connection control survey completed/due <br />Atmospheric Vacuum Breakers (AVB) AA' iC <br />f V / faP-J A yr <br />/V Pressure Vacuum Breakers (PVB) /j-T- trrt\<Hrgy\ <br /> <br /> <br />iXA-faPr- J W- <br /> j fl c>r <br />(t\r qgf. 05 prp by April 2 /y M <br />TitlA 22 of the California Code oTflegulations requires routine monitoring of your water system by a State certifieduaboratory. Sampling <br />must be performed by State certified laboratory personnel or CDO/CTO. All samples shall be taken at the wellhead, except for <br />bacteriological and Lead and Copper sampling. Please be aware that all results for samples analyzed for a system in a calendar month <br />shall be reported to the EHD no later than the tenth day of the following month. The EHD strongly recommends the use of non­ <br />threaded, dedicated sample taps for bacteriological sampling in the distribution system. <br />Bacteriological: Reguired guarterly/msatWy for Total coliform bacteria. Instruct your laboratory to collect a Routine sample once <br />each quarter/month. If a Routine sample tests positive for coliform, instruct your laboratory to collect four/f» Repeats samples within <br />24 hours of being notified by your laboratory and to collect five/are Routine sample(s) the following month, with the results <br />enumerated and chlorine residuals reported all these samples. Notify EHD if more than one of the samples is positive. <br />Nitrates: Required l^/annually.____ __________________________________________________ <br />•-^Nitrites: Required itnwiim^y/once every three years.____________________________________________________ <br />Inorganic Chemicals: Required once every three years. EHD waived monitoring for asbestos and cyanide. <br />X Volatile Organic Compounds (VOCs): Required once every tawe/six years. <br />^ Synthetic Organic Compounds (SOCs): EHD waived monitoring for all SOCs, except for: <br />DBCP- Required once e^^^r/three year(s) and EDB - Required once every three years._____________ <br />Lead and Copper: Required once every saesraths/three years. A sample set of five/ten samples shall be <br />collected from th^disUihutjpn system between the months of June through September, & six months later. <br />Radiological: Qr^s AlphgilRedium"gg8: Required quarterly for one year. EHD waived Gross Alpha <br />monitoring to once every 1 / 3 / 6 / 9 year(s). <br />Secondary (Aesthetics): General Mineral and General Physical are due every three years. <br />Submit a copy of this form with all past due sample results. All past due lab results must be received by:Compliance date for all deficiencies: <br />Please be aware that failure to correct deficiencies by compliance date will result in staff time charges of $98 per hour. <br />Received, b/l// [j._t/SyW( <br />General Description: This system consists of /_wel|(s)C <br />Other backflow prevention devices <br />fay Cpyp-A 7-^0 2___ <br /><3 ziz) <br />- is ~hhSL Cyy&JtA