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UNDERGROUND TANK OFFICIAL INSPECTION R*ORT <br />SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N. San Joaquin Street c� �,�,\ <br />COUNTY NAME <br />Mailing Aon, CA: 5.0.8388 COUNTY # l JLZ) <br />Stockton, CA 85201-0388 <br />488-3420 <br />SITE NAME: k <br />INSPECTION DATE: S <br />SITE ADDRESS: ( C5- o <br />CITY/STATE/ZIP 0 G <br />CHANGES SITE/OWNER/PERMIT? <br />YES NO <br />TANK <br />TANK <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />NUMBER <br />NUMBER <br />NUMBER <br />NUMBER <br />TYPE OF INSPECTION <br />SITE COMPUTER # <br />PER # <br />PER # <br />PER # <br />PER # <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />TANK CONTENTS <br />MAJOR MINOR ',•, <br />PERMIT TO OPERATE <br />1 2 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 4 <br />APPROVED CONSTRUCTION <br />5 6 <br />WRITTEN MONITORING PROCEDURES <br />7 8 <br />APPROVED MONITORING SYSTEM <br />9 10 <br />MONITORING SYSTEM <br />11 12 <br />APPROVED MONITOR FREQUENCY <br />13 14 <br />MONITORING RECORDS MAINTAINED <br />15 16 <br />ACCESS CASING SECURED <br />17 18 <br />PIPING <br />19 20 <br />INVENTORY RECONCILIATION <br />21 22 <br />TANK GAUGING <br />23 24 <br />APPROVED RESPONSE PLAN <br />25 26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 28 <br />SAMPLING <br />29 3D <br />APPROVED TANK REPAIRS <br />31 32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 34 <br />SAFETY HAZARD <br />35 36 <br />CONDITIONS ABATED <br />37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />W4445 <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />46 47 <br />PIPING <br />48 49 <br />FLAMMABLE VAPORS REMOVED <br />50 <br />UNAUTHORIZED RELEASE <br />51 52 <br />SAMPLING <br />53 54 <br />IMPROPER ABANDONMENT <br />55 56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS. <br />57 58 <br />59 <br />R LJVIOLO.R NO <br />❑ <br />❑ <br />- _ <br />VIOL OL. <br />OFFICE: <br />INSP:L,I <br />Ada- � <br />- <br />RECEIVED BY: <br />TITLE: f4� <br />PHONE: <br />BECK: <br />HUT -3 White - O3gmal Yellow - Ownees Copy Pink - File Copy - e✓sx C'. <br />