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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> AI Crow,Pres. San Joaquin•.County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews City of Ripon <br /> Thomas Schubert.D.V.M. San Joaquin County <br /> Daphne Shaw RELEASE (leak) EVALIIATION PROCESS City of Stockton <br /> Harvey Williams,Ph.D. CHECK LIST San Joaquin County <br /> Facility Name: _ <br /> Size: I c� Product: <br /> Tank: <br /> TTime: AP1 2 G, 3G - �g C- <br /> he xeededDate/ 7 << <br /> c <br /> V ' 11 t n << <'. <br /> Check off each step as it is completed. j .: .NE <br /> If completion of any of the steps reveals the reason for exceeding the <br /> allowable variation <br /> t is not necessary to ccmpieta the remainder or the <br /> steps. <br /> Step 1- QTime: <br /> Reco..ds reviewed Date/Time: <br /> Performed By: <br /> Step 2- Q New Reconciliation Date/Time: <br /> Performed Performed By: <br /> Step 3- Q Tank Owner Notified Date/Time: <br /> Performed By: <br /> Step 4- Q Records Reviewed From Date/Time: <br /> Last 0 Balance (Must Performed By: <br /> be performed by qualified <br /> person) <br /> Step 5- Q Facility Physically Date/Time: <br /> Inspected for. Evidence Performed By: <br /> of Leaks <br /> Step 6- Q Calibration on Dispenser Date/Time: <br /> Meters Checked Performed By: <br /> (Complete Meter <br /> Calibration Check Form) <br /> Step 7- Q Hydrostatic Pressure Test Date/Time: <br /> on Piping Performed Performed By: <br /> Step 8- Q Precision Tank Test Date/Time: <br /> Performed Performed By: <br /> (Provide results to SJLHD <br /> Environmental Health) <br /> Step 9- Q Follow-up investigation Date/Time: <br /> as required to be Performed By: <br /> performed by SJLHD <br /> Describe briefly the reason the allowable variation was exceeded: <br /> ctiCL c l VCS ct � .C• � S �, ;{� U +c-_c �I ,Ec: <br /> _t- 7 '1_. C 5.<" f S� u 1 i c C <br /> f '" 11 <br /> I hearby certify this is a true and accurate�reportl. <br /> Signature/Date: <br /> Attach this report to Inventory Reconciliation Sheet where allowable <br /> variation was exceeded. <br /> EH 23 018 REV 5/S9 <br />