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• . . .CIIVC*)" LIST ,..•.•� <br /> Facility Name: '�� C J `a� , . A <br /> TankC: _� S' e: J 00 Product: <br /> The allowable variation was exceeded. Date/Time: <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 I- Records Reviewed , Date/Time: _�-7 9� 3 , <br /> Performed By: ��,,, GuJy�yEyy, <br /> Step 2- � New Reconciliation Date/Time: <br /> Performed Performed By: <br /> Step ]- ❑ Tank Owner Notified Date/Time: <br /> Performed By: <br /> Step 4- ❑ Records Reviewed from Date/Time: <br /> Last 0 Balance (Must Performed By: <br /> be performed by qualified <br /> person) <br /> Step 5- ❑ Facility physically Date/Time: <br /> Inspected for Evidence Performed By: <br /> of Leaks <br /> Step 6- ❑ Calibration on Dispenser Date/Time: <br /> Meters Checked Performed By: <br /> (Complete Meter <br /> Calibration Check Form) <br /> Step 7- ❑ Hydrostatic Pressure Test Date/Time: <br /> on Piping Performed Performed By: <br /> Step 8- ❑ Precision Tank Test Date/Time: <br /> Performed Performed By: <br /> (Provide results to SJLHD <br /> Environmental Health) <br /> Step 9- ❑ Follow-up investigation Date/Time: <br /> as required to be per- Perforued By: <br /> formed by SJUD . <br /> Describe briefly the reason the allowable variation was exceeded: <br /> I Nearby Certify this is a True and Accurate Report. <br /> Signature/Date:�� <br /> Attach this report to Inventory Reconciliation Sheet where allowable variation <br /> vas eNf.PP�I I•d. <br />