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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al 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. RELEASE (leak) EVALUATION PROCESS San Joaquin County <br /> Daphne Shaw City of Stockton <br /> Harvey Williams,Ph.D. CHECK LIST San Joaquin County <br /> Facility Name: Ij.U•J-L7 <br /> Tank: I,L,000 e-iglar Size: 12, =alto✓) Product: <br /> The allowable variation was exceeded. Date/Time: 3 - �� - O <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: 3- IA-90 <br /> Performed By: <br /> Step 2- C]" New Reconciliation Date/Time: - l4 -`?0 <br /> Performed Performed By: ' tea.- 'P• <br /> Step 3- Q' Tank Owner Notified Date/Time: <br /> Performed By: —o --a e_ Tom. <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: 3- 1-4 - 9 0 <br /> Inspected for. Evidence Performed By: <br /> of Leaks <br /> Step 6- ©' Calibration on Dispenser Date/Time: I- � -`30 <br /> Meters Checked Performed By: 141,2rt'e,l- <br /> (Complete Meter �5e-,r l Q- Co: <br /> Calibration Check Form) <br /> Step 7- CEI' Hydrostatic Pressure Test Date/Time: <br /> on Piping Performed Performed By: 1►J EGPIT TtS�iNGa <br /> Step 8- EEr' Precision Tank Test Date/Time: 3 -a 1 - '30 <br /> Performed Performed By: I►.1TECr P_k r T/�t1.1K <br /> (Provide results to SJLHD TESTI e-tGc <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: -Th g <br /> -� c k a i 5 vo,r I0' .a <br /> w �\ e vow. 1 •t, rt o -t'' Q +,v t ✓� 0 R Apa r1l- <br /> r aSo✓� Tti� �:� tr;C. t L th -t'�,e �ro�e 5g 04, 1c _t l <br /> I hearby certify this is a true and accur eport.• <br /> Signature/Date: <br /> Attach this report to Inventory Reco ili tion Sheet where allowable <br /> variation was exceeded. <br /> EH 23 018 REV 5/89 <br />