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,M Facility Date Address WA# Service // ?fcrDu&fa\- rforbuewT Public Health 72(1/02)Page 1 of _ Title 22 of the California Code of Regulations requires routine monitoring of your water system by a State certified laboratory. Sampling must be performed by State certified laboratory personnel. All samples shall be taken at the wellhead, except for bacteriological sampling. The EHD strongly recommends the use of non-threaded, dedicated sample taps for bacteriological sampling in the distribution system. Cross-connection control survey completed Atmospheric Vacuum Breakers (AVB) Pressure Vacuum Breakers (PVB) Double Check Valve Assemblies (DCVA) Reduced Pressure Principle Assemblies Other backflow prevention devices EHD 46-01-001 Revised 01/25/02 / | 0 \ 0C> i TyPeofSyste^^ General Description This system consists of f well(s) and J hydropneumatic tank(s)/ consists of service connections serving a population of j in the surrounding area consists of agricultural, residential, commercial, industrial, rural, pristine, livestock enclosures. Well(s) used for: domestic industrial irrigation fire standby Treatment: Cross-Connection Control '1 bladder tank(s). The distribution system residents/employles/customers/gtudents. General land use PUBLIC WATER SYSTEM PROC (3FFICIAL INSPECTION REPORT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 EAST WEBER AVENUE, 3rd FL, STOCKTON, CA 95202 (209) 468-3420 FAX (209) 468-3433 Bacteriological: Required af^W^fof/monthly. Continue testing ^J^e^/monthly unless a sample tests positive for coliform. After a positive, four repeats must be taken within 24 hours of being notified by your laboratory and five routine samples shall be taken the following month. Please be aware that the bacteriological results collected for a system in a calendar month shall be reported to the EHD no later than the tenth day of the following month. ______________________.1^^, Nitrates: Required ijjg^&^annually. //? '^her <g Nitrites: Required g^^t^once every three years.________________________________ Inorganic Chemicals: Required once every three years. The EHD currently waives asbestos and cyanide. Volatile Organic Compounds (VOCs): Required once every three/six years.________________________ Synthetic Organic Compounds (SOCs): DBCP and EDB are required once every three years. Lead and Copper: Required annually/once every three years. One complete sample set is to be taken between the months of June through September.________________________________________________ Secondary (Aesthetics): General Mineral and General Physical are due every 3 years. Radiological: Required every four years if compliance is met by conducting four consecutive calendar quarterly samples._____________________________________________ Submit a copy of this form with all past due sample results.___________ _________ All past due lab results must be received byS^Z/Z/g /0, Compliance date for all deficiencies: Please be aware that failure to correct deficiencies by compliance date will result in staff time charges of $89 per hour. R.E.H.S. 7 A-V/- Received by Mpcj !3. Z&fz— PWS ID#'./ Phone # t All testable backflow prevention devices are required to be tested by a State certified tester annually and immediately after any installation or repair and the results submitted to the Environmental Health Department (EHD). '■ktpH