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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING San Joaquin County At Crow,Pres. 1601 East Hazelton Avenue City of Manteca Earl Pimentel,Vice Pres. City of Escalon Tommy Joyce,Secy. Stockton, California 95205 James F.Culbertson City of Lodi John D.Mast M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy Virginia Mathews San of Ripon San Joaquin County Thomas Schubert D.V.M. RELEASE (leak) EVALUATION PROCESS City of Stockton Daphne Shaw Harvey Williams,Ph.D. CHECK LIST San Joaquin County Facility Name: Tank: Size: Product: The allowable variation was exceeded. Date/Time: Check off each step as it is completed. If completion of any of the steps reveals the reason for exceeding the allowable variation it is not necessary to complete the remainder of the steps. Step 1- 0 Records reviewed Date/Time: Performed By: Step 2— O New Reconciliation Date/Time: Performed Performed By: Step 3— Tank Owner Notified Date/Time: Performed By: Step 4— Q Records Reviewed From Date/Time: Last 0 Balance (Must Performed By: be performed by qualified person) Step 5- O Facility Physically Date/Time: Inspected for Evidence Performed By: of Leaks Step 6- Calibration on Dispenser Date/Time: Meters Checked Performed By: (Complete Meter Calibration Check Form) Step 7- Q Hydrostatic Pressure Test Date/Time: on Piping Performed Performed By: Step 8- Precision Tank Test Date/Time: Performed Performed By: (Provide results to SJLHD Environmental Health) Step 9- O Follow-up investigation Date/Time : as required to be Performed By: performed by SJLHD Describe briefly the reason the allowable variation was exceeded: I hearby certify this is a true and accurate report. Signature/Date: Attach this report to Inventory Reconciliation Sheet where allowable variation was exceeded. EH 23 018 REV 5/89