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ROUND TANK OFFICIAL <br />ON <br />UkrfERGSA OAQU N PUBLIC HEALTH SERVICES <br />R ,RT <br />CES <br />J <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N. San Joaquin Street <br />Melling Address: P.O. Boz 388 COUNTY # 9 <br />Stockton. CA 95201-0388 <br />b0UR11 nnmL _3",Sti J. <br />VLF <br />468-3420 <br />— p <br />SITE NAME: <br />INSPECTION DATE: <br />SITE ADDRESS: �T N, g <br />bes kka,� <br />CITY/STATE/ZIP S fpG�1 Cl <br />CHANGES SITE/OWNER/PERMIT? YES <br />NO <br />TANK 1 <br />TANK <br />TANK <br />TANK <br />FORM AAND/OR B SUBMITTED? <br />COMPUTER <br />NCOMPUTER <br />NUMBER <br />NUMBER <br />PER # <br />NUMBER <br />PER # <br />NUMBER <br />PER # <br />PER # <br />TYPE OF INSPECTION <br />SITE COMPUTER# <br />r 0GI- fl K-0-. <br />a.3 1 (>? c <br />6 <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK UNK CON Nis <br />MAJOR MINOR i <br />PERMIT TO OPERATE 1 <br />2 w <br />CHANGE IN CONDITIONS TO OPERATE 3 <br />4 ✓ <br />APPROVED CONSTRUCTION 5 <br />6 / <br />WRITTEN MONITORING PROCEDURES 7 <br />8 <br />APPROVED MONITORING SYSTEM 9 <br />10 _ <br />MONITORING SYSTEM 11 <br />12 _ <br />APPROVED MONITOR FREQUENCY 13 <br />14 <br />MONITORING RECORDS MAINTAINED 15 <br />16 <br />ACCESS CASING SECURED 17 <br />18 / <br />✓ <br />PIPING 19 <br />20 <br />INVENTORY RECONCILIATION 21 <br />122 1 <br />TANK GAUGING 23 <br />24 <br />APPROVED RESPONSE PLAN 25 <br />26 <br />UNAUTHORIZED RELEASE OCCURRENCE 27 <br />28 <br />SAMPLING 29 <br />3D <br />APPROVED TANK REPAIRS 31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED 33 <br />34 <br />SAFETY HAZARD 35 <br />36 <br />CONDITIONS ABATED <br />37 <br />F. h cwt c'; �'es /��,s,' <br />b • /� %.. <br />TEMPORARY TANK CLOSJRE <br />REMOVAL OF RESIDUAL 38 <br />39 <br />FLAMMl BLE VAPORS REMOVED 40 <br />ACCESS LOCATIONS SEALED 41 <br />42 <br />POWER DISCONNECTED <br />43 <br />OWNER/OPERATOR MONITORING 44 <br />45 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS 46 <br />47 <br />PIPING 48 <br />49 <br />FLAMMABLE VAPORS REMOVED 50 <br />UNAUTHORIZED RELEASE 51 <br />52 <br />SAMPLING 53 <br />54 <br />IMPROPER ABANDONMENT 55 <br />56 <br />THE MARKED ITE S REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />,CIA <br />F LOjCVS: <br />MAJOR 57 MINOR NO 58 59 <br />❑ ❑ ❑ <br />16 cj <br />i ` <br />VIOL VIOL. VIOL. <br />OFFICE: <br />INSP aZA-- - r <br />RECEIVED Y' <br />TITLE:,,; <br />PHONE: <br />RECK: <br />HL1T-3 WNte - Orlainal YOM - Ownees Coov Pink - Fila Cenv <br />