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UN%,sAGROUND TANK OFFICIAL INSPECTION Re*AT <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 # f3' 9 <br />4R&3420 <br />SITE NAME: IZ <br />�W <br />INSPECTION DATE: 1 <br />SITE ADDRESS: <br />/ <br /><�-r <br />CITY/STATE/ZIP 754+4f4 <br />7�-r wy <br />lig <br />I <br />!TANK <br />CHANGES SITE <br />YES <br />NO <br />TANK <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUT h <br />PER B �� <br />t7 COMPUTER <br />PUR #ER <br />COMPUTE <br />PER BER <br />COMPUTER <br />NUMPER BER <br />TYPE OF INSPECTION SITE COMPUTER # <br />{(� <br />EX t'OAT9 <br />DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />TANK CONIEKTS <br />MAJOR MINOR <br />PERMIT TO OPERATE <br />1 <br />2 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 <br />4 <br />APPROVED CONSTRUCTION <br />5 <br />6 <br />WRITTEN MONITORING PROCEDURES <br />7 <br />8 <br />APPROVED MONITORING SYSTEM <br />9 <br />10 <br />MONITORING SYSTEM <br />11 <br />12 <br />APPROVED MONITOR FREQUENCY <br />13 <br />14 <br />MONITORING RECORDS MAINTAINED <br />15 <br />16 <br />ACCESS CASING SECURED <br />17 <br />18 <br />PIPING <br />19 <br />20 <br />INVENTORY RECONCILIATION <br />21 <br />22 <br />TANK GAUGING <br />23 <br />24 <br />APPROVED RESPONSE PLAN <br />25 <br />26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 <br />28 <br />_ <br />SAMPLING <br />29 <br />30 <br />_ <br />APPROVED TANK REPAIRS <br />31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 <br />34 <br />SAFETY HAZARD <br />35 <br />36 <br />_ <br />CONDITIONS ABATED <br />37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />38t42 <br />FLAMMABLE VAPORS REMOVED <br />40 <br />ACCESS LOCATIONS SEALED <br />41POWER <br />DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />44 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />46 <br />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 ITE S REPRE�EN VIIOLATIONS A D MUST BE <br />CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />744�� V <br />FOLLOWS: <br />57 <br />7MINOR 58 <br />59 <br />MAJOR NO <br />❑ ❑ <br />IX <br />VIOL. VIOL. VIOL <br />OFFICE: <br />CEIVED BY: <br />LIN'SP: <br />PHONE: <br />RECK: <br />LE: RF, <br />HUT -3 White - Original Yellow - Owners Copy Pink - File Copy siae O <br />