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UR.ERGROUND TANK OFFICIAL INSPECTION Rrs6RT <br /> SAN JOAOUIN 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 # <br /> 488-3420 <br /> SITE NAME: /_ fo �GI t INSPECTION DATE: <br /> SITE ADDRESS: �(�(DUO g � 1llo� 201 CITY/STATE/ZIP ;$ <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK 5 TANK (P TANK 494 TANK a <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> TYPE OF INSPECTION SITE COMPUTER# NUMBER NUMBER NUMBER NUMBER <br /> s I Q n PER# PER# PER#F PER# <br /> EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK TANK CON NIS <br /> MAJOR MINOR <br /> PERMIT TO OPERATE 1 2 <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 8 \ (\ <br /> WRITTEN MONITORING PROCEDURES 7 8 f ) 1 <br /> APPROVED MONITORING SYSTEM 9 <br /> MONITORING SYSTEM 11 12 ✓ ✓ ✓ `/ <br /> APPROVED MONITOR FREQUENCY 13 14 <br /> MONITORING RECORDS MAINTAINED 15 16 <br /> ACCESS CASING SECURED 17 18 <br /> PIPING 19 20 (/() <br /> INVENTORY RECONCILIATION 21 22 <br /> TANK GAUGING 23 2p <br /> APPROVED RESPONSE PLAN <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 28 <br /> SAMPLING 2g 30 <br /> APPROVED TANK REPAIRS 31 32 <br /> UNAUTHORIZED RELEASES REPORTED 33 34 <br /> SAFETY HAZARD 35 36 <br /> CONDITIONS ABATED 37 <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL 38 39 `/ ✓ j <br /> FLAMMABLE VAPORS REMOVED 40 ✓j `✓ <br /> ACCESS LOCATIONS SEALED 41 42 <br /> POWER DISCONNECTED M 43 <br /> OWNER/OPERATOR MONITORING 44 45 <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 1/ <br /> SAMPLING 53 f4 <br /> IMPROPER ABANDONMENT 55 56 <br /> THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONEI FOLLOWS: <br /> 57 58 59 <br /> MAJOR NO <br /> VIOL. ❑ VIOLR ❑ VIOL❑ <br /> OFFICE: INSP: . RECEIVED BY: NO Cyned CjLcr <br /> r V <br /> TITL : PHONE: RECK: <br /> HUT-3 WhIte-Original Yellow-Owner's Copy Pink-File CODV <br />