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BOARD OF TRUSTEES SAN13AQUlN LOCAL HEALTH DIST*r SERViNG <br /> Jamas Culbertson, Pres. City of Lodi <br /> PalrWa E. Vannucci, Secy. San Joaquin County <br /> 1601 East Hazelton Avenue, P. ©. Box 2009 <br /> Anthonatle Von Spronsen City of Escalon <br /> Earl Pimentel Stockton, California 95201 City of Manteca <br /> Fern ®ugbee '209/4$6-6781 City of Ripon <br /> Oanlei L. Flores City of Stockton <br /> John D. Mast. M.O. City of Tracy <br /> wimem J. Weds Jog[ Khanna. M.O., M.P.H., District Health Officer San Joaquin County <br /> Macy Anna tore San Joaquin County <br /> Facility Name <br /> r <br /> Address <br /> Date of Inspection Inspector <br /> MONITORING ALTERNATIVE 05 <br /> i✓ Annual precision test on tank(s) and piping. <br /> t- Daily -inventory reconciliation with submission of quarterly statement regarding <br /> compliance with allowable variation.. <br /> r ' <br /> pipeline leak detectors on pressurized piping. <br /> 1 . Daily operational check of suction piping function. <br /> Calibrated meters for inputs and withdrawals: <br /> Weights and Measures sticker <br /> �- Certification by qualified repairman <br /> Implementation of this: monitoring alternative requires that the following CIRCLED items <br /> be completed by the specified dates. <br /> I .: Precision test(s) must be performed by f/ � ' and results submitted to <br /> this office within 30 days of the test. <br /> 2. Pipeline leak detectors must be installed on pressurized piping by <br /> f3. Daily inventory reconciliation must be started immediately, with records maintained <br /> `- ' at the facility for review. <br /> 4 Document daily check of suction piping function starting immediately. <br /> C5'. Submit quarterly statement to this office that allowable variation on inventory <br /> reconciliation has not been exceeded or a list of dat s and variations that <br /> exceeded allowable.* The first statement is due by / <br /> 6� Dispenser meter(s) must be calibrated by _ Z417 6 !lv with copy of <br /> certification or Weights and Measures sticker number submitted to this office. <br /> If the above compliance dates cannot be met, contact this office prior to the specified <br /> date. <br /> * If allowable daily inventory variation is exceeded, refer to Section 2644( f) for <br /> required actions. <br /> 3-86 UGT I <br />