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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: cJtot,K�O✓b U�,��e.c� �aC�nC01 D'S'I"� �o� t��5 5F�'VIZ.eJ <br /> Tank: Size: gppO Product. UrN1ea.�Q CxaS <br /> The allowable variation was exceeded. Date/Time: 1 - i0-9 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- [ZI <br /> Records reviewed Date/Time: 1-10- 10 8: 30a•�'" <br /> Performed By: e,or e Cha,-ler <br /> Step 2- [Zf' New Reconciliation Date/Time: -IQ :110 ate. <br /> Performed Performed By: : Q,p,rc C►�ar4�5 <br /> Step 3- � Tank Owner Notified Date/Time: <br /> Performed By: Cv.arles Le �bwe <br /> Step 4- 0' Records Reviewed From Date/Time: 1-16 -9 9'-JO <br /> Last 0 Balance (Must Performed By: <br /> be performed by qualified <br /> person) <br /> Step 5- [ Facility Physically Date/Time: 1 -10- `lU 8 g <br /> Inspected for Evidence Performed By: C�.a r- -9_ <br /> of Leaks <br /> Step 6- �J Calibration on Dispenser Date/Time: 1 ' g'9 <br /> Meters Checked Performed By: <br /> Q-�e-V' <br /> (Complete Meter Servers. Co. <br /> Calibration Check Form) <br /> Step 7- Q' Hydrostatic Pressure Test Date/Time: -i5"yd al-9d <br /> on Piping Performed Performed By: PY-eC4"s'0A u5fr;eS <br /> Step 8- Q� Precision Tank Test Date/Time: I-IS-9cD O <br /> Performed Performed By: rec:S:0ti sr�I�e_ <br /> (Provide results to SJLHD <br /> Environmental Health) <br /> Step 9- 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: ` N*'$Ta4c c5 <br /> q cj� f 2 r Q^ i ct WN P_;t'a✓- a✓% 0 v a✓-Vc Inst.,-'E- 5k Dw 5 j h Q. c J G v e <br /> dtSCdve.r., w`.�� -�'ar.�c wa e -F VQ +i ;ve v; S <br /> t1C rh ' cC4v :v r2 e <br /> ve o✓' Vvay have_ �"tJSCa1Cu la-k�-a his f v e_l Arop <br /> I hearby crertify this is a true and ccurate report.- <br /> Signature/Date: —( —tin <br /> Attach this report to Inventory Reconciliation Sheet where allowable <br /> variation was exceeded. <br /> EH 23 018 REV 5/89 <br />