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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) EVALUATION PROCESS City of Stockton <br /> Harvey Williams,Ph.D. CHECK LIST San Joaquin County <br /> Facility Name• `t -.� �v, ,v. 14 S � SSC ��Vic` <br /> Tank: l C,('('-, Size: Product: �cc�S� I -� <br /> The allowable vas; ati en was exceeded. Date/Time: 9 -- i F"' <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 Data/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 /> I hearby certify this is a true and accurate report. <br /> Signature/Date: C " w on <br /> Attach this report to Inventory Reconciliation Sheet where allowable <br /> variation was exceeded. <br /> EH 23 018 REV 5/89 <br />