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Uh-rERGROUND TANK OFFICIAL INSPECTION Re.10ORT <br /> SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N.Sen Joaquin Street <br /> Mailing Address: P.O.Boz 388 <br /> COUNTY NAME Stockton.CA 95201-0388 COUNTY OUNTY # <br /> SITE NAME: INSPECTION DATE: <br /> SITE ADDRESS: CITY STATE/ZIP �U <br /> CHANGES SITE/OWNER/PERMIT? YES NO TA TANK TANK TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> TYPE OF INSPECTION SITE COMPUTER# NUMBER NUMBER NUMBER NUMBER <br /> PER# PER# PER # PER# <br /> EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK TAMCOI^E"1s �,'• <br /> MAJOR MINOR <br /> PERMIT TO OPERATE 1 2 <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 6 <br /> WRITTEN MONITORING PROCEDURES 7 8 <br /> APPROVED MONITORING SYSTEM 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 /9 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 <br /> APPROVED TANK REPAIRS <br /> UNAUTHORIZED RELEASES REPORTED <br /> SAFETY HAZARD <br /> 353 _ <br /> CONDITIONS ABATED <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL W4445 <br /> FLAMMABLE VAPORS REMOVED <br /> ACCESS LOCATIONS SEALED <br /> POWER DISCONNECTED <br /> OWNER/OPERATOR MONITORING <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 <br /> SAMPLING 53 54 <br /> IMPROPER ABANDONMENT 55 56 <br /> THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONE) FOLLOWS:1- 57 ' <br /> 58 59 <br /> VIOLOR ❑ VIOLL..R ❑ VIOL❑ <br /> OFFICE: INSP: RECEIVED BY: <br /> TITLE: 1p t L, PHONE: RECK: <br /> HUT-3 Wilts-Original Yellow-Owner's Copy Pink-File Copy 'Wh6 <br />