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BOARD OF TRUSTEES Sif )AQUIN LOCAL HEALTH DIS T SERVING <br /> James Culbertson, Pres. City of Lodi <br /> Patricia E. Vannuccl, Sec'y. 1601 East Nazeln:iv3nue San Joaquin y <br /> Anthonette Van Spronsen , P. 0. BOX 2009 y n Count <br /> City of Eacalon <br /> Earl Plmentel Stockton, Callfornla 95201 City of Manteca <br /> Fern Bupbee 209/466-6781 City of Ripon <br /> Daniel L. Flores City of Stockton <br /> John D. Mast, M.D. City of Tracy <br /> William J. Wade Jopl Khanna, M.D., M.P.H., District Health Officer San Joaquin County <br /> Mary Anna Love San Joaquin County <br /> Facility Name <br /> Address ; n <br /> Date of Inspection Inspector �/_1V1 <br /> MONITORING ALTERNATIVE Y5 <br /> )r;Annual precision test on tank(s) and piping. <br /> 4,/Daily inventory reconciliation with submission of quarterly statement regarding <br /> compliance with allowable variation. <br /> �J 4 Pipeline leak detectors on pressurized piping. <br /> Daily operational check of suction piping function. <br /> i- 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 /> 1 . Precision test(s) must be performed by U - 3o- and results submitted to <br /> this office within 30 days of the test. ijd, --1 <br /> Cool <br /> 2. Pipeline leak detectors must be installed on pressurized piping by <br /> 3. Daily inventory reconciliation must be started immediately, with records maintained <br /> at the facility for review. <br /> 04.' 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 dates and variations that <br /> exceeded allowable.* The first statement is due by <br /> 06. Dispenser meter(s) must be calibrated by — = 3r_— 5� � 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 1 <br />