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Date: <br />Address: <br />Phone:Received By:Type of Service: <br />Loo 3 <br />l-oo 5" <br />CROSS-CONNECTION CONTROL <br /> Cross-Connection Control Survey Double Check Valve Assemblies (DCVA) <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 />AM) <br />o V <br />To <br />PWS ID #: yiQILO'L <br />xvA#:O^bl^ob <br />yjfckX- ft-1 . Tv t5 <br />HO ___ <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 kf^S^tfy/monthly. Continue testing ^W^yty/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 tyiAftd/ky/annually.____________________________________________________ ______ <br />Nitrites: Required <ffi\ftriy/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 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 />Please be aware that failure to correct deficiencies by compliance date will result in staff time charges of $89 per hour. <br />EHD 46-01-001 Page 1 of —1— SPWS Official lnsPec,ion ReP°rt <br />Revised 02/21/03 <br />GENERAL DESCRIPTION <br />This system consists of I well(s) and k hydro pneumatic tank(s) 0 bladder tank(s). The distribution system <br />consists of <7 service connections serving a population of 7^-5 residents/employees/customers/students. General land use in <br />the surrounding area consists opagricultural, residential, conjnjrrc-ial, industrial, rural, pristine, livestock enclosures.Well(S) USED for: r DOMESTIC INDUSTRIAL IRRIGATION FIRE STANDBY <br />Treatment:___________________________________________________________________ <br />San Joaquin unty Environmental Healt epartment <br />304 East Weber Ave, 3rd Floor Stockton, CA 95202-2708 <br />Phone: (209) 468-3420 Fax: (209) 468-3433 Web: WWW.SJCEHD.COM <br />SMALL PUBLIC WATER SYSTEM PROGRAM OFFICIAL INSPECTION REPORT <br />Facility Name: UQVJfcR $f\Cz <br />\0lOQ blv <br />Type of System: HU53 R.E.H.S.: V-JICWl HA <br />Received Bv: