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COUNTY NAME <br />ITE NAME: <br />UA /GROUND TANK OFFICIAL INSPECTION RE�tT <br />T SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMME ET,1L� HEeAL T H DIVISION <br />Meiling Address: P.O. Bos 388 <br />Stakton, CA 95201-0388 <br />SITE ADDRESS: <br />CHANGES SITE/OWNER/PERMIT? <br />FORM A AND/OR B SUBMITTED?_ <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 REPARS <br />UNAUTHORIZED RELEASES REPORTED <br />SAFETY HAZARD 4 <br />CONDITIONS ABATED <br />TEMPORARY TANK CLOSURE <br />CITY/STATE/ZIP <br />COUNTY # 3(? <br />INSPECTION DATE: �� 7 <br />TANK <br />TANK <br />TANK 3 <br />TANK <br />COMPUTER DqNUM3FR <br />COMPUTER a j <br />NUMBER O/ <br />NNUMBERERO� <br />NUMBER <br />PERMANENT TANK CLOSURE <br />PER / <br />PER <br />PER a <br />PER 4 _^ <br />t W CONIENTS <br />3 4 <br />5 6 <br />7 B <br />9 to <br />II 12 <br />13 14 <br />15 16 <br />F17 IS <br />19 20 <br />23 24- <br />-...... <br />25 26 <br />27 26 <br />29 30 <br />31 32 <br />33 34 <br />35 :i <br />REMOVAL OF RESIDUAL' <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />P44 <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />46 <br />PIPING <br />46 <br />FLAMMABLE VAPORS REMOVED <br />50 <br />UNAUTHORIZED RELEASE <br />51 <br />SAMPLING <br />53 <br />IMPROPER ABANDONMENT <br />55 <br />IMUSf MARK <br />57 58 59 <br />MA.IOR ❑VIOL ❑ VIOL. ❑ <br />NO <br />VIOL. <br />42 <br />43 <br />49 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />m <br />IITITLE: �;t4� <br />HUT -3 White - 01191nel Yen" - Owner's Cony Phl, - File Capv �''�� --�� <br />PHS 178 (4196) <br />