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'-GNDERGROUND TANK OFFICIAL INSPECTIO*fIEPORT <br />SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N, San Joaquin Street <br />COUNTY NAME MaStockton. CA 95201-0388 ilinAddress: P.O. 8 Z ci <br />HUT -3 White - Original Yellow -Owner's Copy Pink - Rio Copy sixth tl. <br />408-3420 bU0111I S J <br />SITE NAME: IN L L/ <br />UOr J <br />INSPECTION DATE: <br />SITE ADDRESS: �6� ����� <br />r%_� <br />CITY/STATE /ZIPL C d <br />CHANGES SITE/OWNjj <br />Y S NOTANK <br />//FORM <br />TANK TANK <br />AAND/OR B S <br />TY OF INSPE IONUTER # <br />NUMBER <br />R <br />COMPUTER COMPUTER COMPUTER <br />NUMBER NUMBER NUMBER <br />//� <br />PER #PER # PER * <br />OPERATIONAL TANKTANK corrlFNlsMAJOR <br />EXPDATE EXP. DATE EXP. DATE <br />MINORPERMIT TO OPERATE1 2CHANGE <br />IN CONDITIONS 3 4APPROVED <br />CONSTRUCTIO5 6WRITTEN <br />MONITORING PR7 8APPROVED <br />MONITORING 9 10 <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 24 <br />APPROVED RESPONSE PLAN 25 26 <br />UNAUTHORIZED RELEASE OCCURRENCE 27 28 <br />SAMPLING 29 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 <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />W43 <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS 46 47 <br />PIPING 48 q9 <br />FLAMMABLE VAPORS REMOVED 50 <br />1 I <br />UNAUTHORIZED RELEASE 51 52 <br />SAMPLING 53 54 <br />l <br />IMPROPER ABANDONMENT 55 56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS: <br />✓ <br />MAJOR 57 MINOR 58 NO %5 <br />❑ ❑ <br />VIOL. VIOL. VIOL. <br />OFFICE: <br />!lam , <br />RECEIVED BY:E:SjM <br />TINSLF <br />PHONE <br />RECK: <br />HUT -3 White - Original Yellow -Owner's Copy Pink - Rio Copy sixth tl. <br />