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Uft-eRGROUND TANK OFFICIAL INSPECTION RN,4RT <br /> SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ,o ENVIRONMENTAL HEALTH DIVISION <br /> COUNTY NAME445 N.San JoaquinStreet <br /> mailing Address: P.O.Box 388 <br /> Q [� Stockton,CA 95201-0388 <br /> 468-3420 COUNTY # I <br /> SITE NAME: <br /> INSPECTION DATE: <br /> SITE ADDRESS: 3 45 <br /> 4L- CITY/STATE/ZIP S-Q <br /> CHANGES SITE YES N TANK <br /> FORM A AND/OR B SUBMITTED? TANK 1 TANK TANK <br /> TYPE OF I <br /> COMPUTER COMPUTER COMPUTER COMPUTER <br /> NSPECTION SITE COMPUTER# NUMBER NUMBER NUMBER <br /> PER# NUMBER <br /> P <br /> PER# PER # PER # <br /> (J EXP.DATE EXP.DATE EXP. <br /> OPERATIONAL TANK 1AMc¢NlIENTs DATE EXP DATE <br /> MAJOR <br /> PERMIT To OPERATE 1 2 MINOR <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 6 <br /> WRITTEN MONITORING PROCEDURES 7 8 _ <br /> APPROVED MONITORING SYSTEM 9 10 <br /> MONITORING SYSTEM 11 12 <br /> APPROVED MONITOR FREQUENCY 13 14 �^ y^resJe/Y�C-� <br /> MONITORING RECORDS MAINTAINED 15 16 / 0 _ 1 <br /> ACCESS CASING SECURED 17 19 <br /> PIPING 19 20 <br /> INVENTORY RECONCILIATION 21 22 YZUI, <br /> TANK GAUGING 23 24 -a3-9� re��,I <br /> APPROVED RESPONSE PLAN 25 26 <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 2B LtNv <br /> SAMPLING 29 30 <br /> APPROVED TANK REPAIRS 31 32 <br /> _._. <br /> UNAUTHORIZED RELEASES REPORTED 33 34 <br /> SAFETY HAZARD 35 36 <br /> CONDITIONS ABATED 37 <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL W4445 <br /> 39 '- <br /> FLAMMABLE VAPORS REMOVED <br /> ACCESS LOCATIONS SEALED 42 <br /> POWER DISCONNECTED 43 <br /> OWNER/OPERATOR MONITORING <br /> PERMANENT TANK CLOSURE <br /> REMOVAL OF RESIDUAL MATERIALS 46 47 <br /> PIPING 48 49 <br /> FLAMMABLE VAPORS REMOVED 50 <br /> UNAUTHORIZED RELEASE 51 52 <br /> SAMPLING53 54 <br /> IMPROPER ABANDONMENT 55 56 <br /> THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONE) F OWS: <br /> MAJOR 57 58 MINOR NO 59 I <br /> VIOL. ❑ VIOL. ❑ VIOL❑ • • e <br /> OFFICE: INSP: <br /> : m o . <br /> TITL F�, 14 �a 10 75A BECK: <br /> C� Y� <br /> uIIT—a Wnso.nnW..I Pink-Rio r.m� - s;kn C, 1 <br />