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3.AM< <br />Facility Date <br />Address <br />WA# <br />Service <br />hydropneumatic tank(s)/bladder tank(s). The distribution system <br />CDO: <br />roo 4 4* <br />Page 1 of <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 />EHD 46-01-001 <br />Revised 02/13/03 <br />All past due lab results must be received by:______________________Compliance date for all deficiencies: | <br />Please be aware that failure to conect deficiencies by compliance date will result in staff time charges of $93 per h! <br />General Description <br />This system consists of <br />consists of <br />kLL PUBLIC WATER SYSTEM PR <br />OFFICIAL INSPECTION REPORT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />304 EAST WEBER AVENUE, 3rd FL, STOCKTON, CA 95202-2708 <br />(209) 468-3420 FAX (209) 468-3433 <br />LdaaJ SkG PlAZ-A <br />Type of System j i i rj <br />Bacteriological: Required qwW»ly/monthly. Continue testing q^Mterty/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 /> Nitrates: Required jfWartwly/annually. <br />‘ ’ 1 TMtrites: Required q/hrtwri^ 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/once every three years. 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: Gross Alpha & Radium 228 compliance is met by conducting four consecutive calendar <br />quarterly samples. Additional monitoring: <br />Submit a copy of this form with all past due sample results. <br />R.E.H.S. <br />Received by . <br />12 <br />Vb\ 20^ <br />Phone # <br />]well(s) and <br />service connections serving a population of 7 residehts/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 industrial irrigation fire standby <br />Treatment: NJ | A CDO:NJ { A_________________________________ <br />Cross-Connection Control <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.