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L °RGROUND TANK OFFICIAL INSPECTION i ORT <br />SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N. San Joaquin Street <br />Mailing Address: P.O. Box 388 <br />COUNTY NAME Stockton, CA 95201-0388 COUNTY OUNTY # <br />SITE NAME: ,/ . 1 INSPECTION DATE: %' S <br />SITE ADDRESS: 30 CITY/STATE/ZIP 'O <br />CHANGES SITE/OWNER/PERMIT? YES NO <br />FORM A AND/OR B SUBMITTED? <br />TANK <br />COMPUTERCOMPUTER <br />NUMBER �O?ly <br />PER # <br />EXP. DATE <br />TANK deL <br />NUMBER �a/� <br />PER # <br />EXP. DATE <br />TANK TANK V <br />COMPUTER COMP UTEf <br />NUMBER /0/::� NUMBER /e <br />PER # �iv���p� PER # <br />EXP. DATE EXP. DATE <br />TYPE OF INSPECTION <br />�V <br />SITE COMPUTER # <br />OPERATIONAL TANK <br />PERMIT TO OPERATE <br />CHANGE IN CONDITIONS TO OPERATE <br />APPROVED CONSTRUCTION <br />WRITTEN MONITORING PROCEDURES <br />APPROVED MONITORING SYSTEM <br />MONITORING SYSTEM <br />APPROVED MONITOR FREQUENCY <br />MONITORING RECORDS MAINTAINED <br />ACCESS CASING SECURED <br />PIPING <br />INVENTORY RECONCILIATION <br />TANK GAUGING <br />APPROVED RESPONSE PLAN <br />UNAUTHORIZED RELEASE OCCURRENCE <br />SAMPLING <br />APPROVED TANK REPAIRS <br />UNAUTHORIZED RELEASES REPORTED <br />SAFETY HAZARD <br />CONDITIONS ABATED <br />TANK CONTENTS <br />42 <br />POWER DISCONNECTED <br />51 <br />MAJOR MINOR <br />2 <br />X <br />Y, <br />V_ -- <br />3 4 <br />5 6 <br />7 1 8 <br />9 110 <br />11 112 <br />13 114 <br />15 116 <br />17 118 <br />19 120 <br />21 22 <br />23 24 <br />25 26 <br />27 28 <br />29 30 <br />31 32 <br />33 34 <br />35 136 <br />/ 37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />38 39 <br />FLAMMABLE VAPORS REMOVED <br />40 <br />49 <br />ACCESS LOCATIONS SEALED <br />41 <br />42 <br />POWER DISCONNECTED <br />51 <br />43 <br />OWNER/OPERATOR MONITORING <br />44 <br />45 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />46 47 <br />PIPING <br />48 <br />49 <br />FLAMMABLE VAPORS REMOVED <br />50 <br />UNAUTHORIZED RELEASE <br />51 <br />52 <br />SAMPLING <br />53 <br />54 <br />IMPROPER ABANDONMENT <br />55 <br />56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) FOLLOWS: <br />57 58 59 <br />MAJOR OR NO <br />VIOL. ❑ VIOL ❑ VOL. ❑ <br />OFFICE: INSP: RECEIVED BY: <br />TITLE: C /j/S. PHONE/ZO�) i�6 333 BECK: <br />HUT -3 White - Original Yellow - Owner's Copy Pink - File Copv <br />