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Boum OF TRUSTM SAN JOAQUIN LOCAL HEALTH DISTRICT 8rF.ttwt <br /> Al crow.Fres. San Joaquin County <br /> Earl PknentN,Vice Fres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce.Selly. Stockton,California 95205 City of Escaion <br /> James F.Culbertson City of Lodi <br /> John 0.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) EVALUATION PROCESS City of Stockton <br /> Haney WI1IIama.PhD. CHECK LIST San Joaquin County <br /> Facility Name: S USD Thawsponta ion De-pt <br /> Tank: 1 Size: 10.000 Product. Dtiesee <br /> The allowable variation was exceeded. Date/Time: 10/29/90 6 :30 a.m. <br /> Check off each step as it is completed. <br /> If completion of any of the steps reveals the reason for exceeding the <br /> allowable variation it is not necessary to complete the remainder of the <br /> steps. <br /> Step 1- Q Records reviewed Date/Time: 10/29/90 7:30 a.m. <br /> Performed By: B. Banks <br /> Step 2- Q New Reconciliation Date/Time: 10/29/90 8:30 a.m. <br /> Performed Performed By: D. Bnq eth aAdt <br /> Step 3- Q Tank Owner Notified Date/Time: ic, �4 -- `i <br /> Performed By: \ - <br /> Step 4- Q Records Reviewed From Date/Time: <br /> Last 0 Balance (Must Performed By: <br /> be perforated 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: 13 t 4 ck v«d <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 /> VC\ <br /> f C_. "C- <br /> I <br /> CI hearby certify this is a true and accurate report.- <br /> Signature/Date: <br /> Attach this report to Inventory Reconciliation Sheet where allowable <br /> variation was exceeded. <br /> EH 23 018 REV 5/89 <br />