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UhweRGROUND TANK OFFICIAL INSPECTION R"6RT SAN JOAQUIN PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N.San Joaquin Street 6 Mailing Address. P.O.Box 388 COUNTY NAME�Sa44./ �O � Stockton,CA 95201 0388 COUNTY # 4683420 SITE NAME: //` INSPECTION DATE: SITE ADDRESS: it GRwl Pd, CITY/STATE/ZIP S+0&K4BYy�/� CHANGES SITE YES NO TANK TANK TANK TANK FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER TYPE OF INSPECTION SITE COMPUTER# NUMBER NUMBER NUMBER NUMBER •Ow-1-IPER# PER# PER # PER # Ci I oS EXP.DATE EXP.DATE EXP.DATE EXP.DATE OPERATIONAL TANK TANK CONTENTS MAJOR I MINOR eC ^3- PERMIT TO OPERATE 1 2 CHANGE IN CONDITIONS TO OPERATE 3 4 APPROVED CONSTRUCTION 5 6 WRITTEN MONITORING PROCEDURES 7 8 _ APPROVED MONITORING SYSTEM 9 10 MONITORING SYSTEM 11 12 APPROVED MONITOR FREQUENCY 13 14 MONITORING RECORDS MAINTAINED 15 16 ACCESS CASING SECURED 17 18 PIPING 19 20 _ INVENTORY RECONCILIATION 21 22 TANK GAUGING 23 124 APPROVED RESPONSE PLAN 25 126 UNAUTHORIZED RELEASE OCCURRENCE 27 28 __- SAMPLING 29 30 APPROVED TANK REPAIRS 31 32 M�i UNAUTHORIZED RELEASES REPORTED 33 34 SAFETY HAZARD 35 38 CONDITIONS ABATED 37 TEMPORARY TANK CLOSURE REMOVAL OF RESIDUAL 38 39 FLAMMABLE VAPORS REMOVED 40 ACCESS LOCATIONS SEALED 41 42 POWER DISCONNECTED 43 OWNER/OPERATOR MONITORING 44 45 p PERMANENT TANK CLOSURE � µ' REMOVAL OF RESIDUAL MATERIALS 46 47 PIPING 48 49 - FLAMMABLE VAPORS REMOVED 50 UNAUTHORIZED RELEASE 51 52 SAMPLING 53 54 IMPROPER ABANDONMENT 55 58LL THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST Re C1nIRI,f:IFD A, SYSTEM STATUS(MUST MARK ONE) FOL OWS: d OT A 7 58 59 6ecl a 11 /000 11 -3S VIOL 5LJ VIOL ❑ VOL.❑ 70 Z Or - OFFICE: INSP: r B0 RECEIVED BY: TITLE:SF-A)i01 RC HS. PHONE:Lzoq) 5 REC;K II �`d'(q�fZ Fill Whft -Original Yellow-Ownees Copy Pink-File Copy Sinn m M