Laserfiche WebLink
.C11ECK 1.1 ST . . , •. .,..•.• • <br /> Facility flame: <br /> Tankv: _ _ Size., Product: /M „ <br /> The allovable 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 1- Records Reviewed Date/Time: �''p10 -9� - �; yQ/oay <br /> Performed By: =� �AAmr� <br /> Step 2- ® New Reconciliation Date/Time: _Q_ �,l _7j 07 <br /> Performed Performed B • _ M <br /> Ste J- e: • w..� <br /> P Tank Owner Notified Date/Time: <br /> Performed By: <br /> Step 4- El Records Reviewed from Date/Time: <br /> Last 0 Balance (Must Performed By: <br /> be performed by qualified <br /> person) <br /> Step 5- E] Facility physically Date/Time: <br /> Inspected for Evidence Performed By: <br /> of Leaks <br /> Step 6- El Calibration on Dispenser Date/times <br /> Meters Checked Performed By: <br /> (Complete Heter <br /> Calibration Check Form) <br /> Step 1- E] Hydrostatic Pressure Test Date/Time: <br /> on Piping Performed Performed By: <br /> Step 8- E] Precision Tank Test Date/Time: <br /> Performed Performed By: <br /> (Provide results to SJUID <br /> Environmental Health) <br /> Step 9- El Follow-up investigation Date/Time: <br /> as required to be per- Perforr:ed By: <br /> formed by SJUID . <br /> Describe briefly the reason the allowable variation was exceeded: <br /> 1 Ilea:by Certify this is a True and Accurate Report. <br /> Signature/Date: , -j«� y„ <br /> Attach this report to Inventory Reconciliation Sheet where allowable variation <br /> was c�ccedcJ. <br />