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U1401,eRGROUND TANK OFFICIAL INSPECTION Rimm BRIT <br />SAN JOAOUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N. San Joaquin Street <br />COUNTY NAME Mailing Address: P.O. Box 388 <br />Stockton, CA 95201-0388 COUNTY # <br />468-3420 <br />SITE NAME: !1 <br />INSPECTION DATE:3_� g <br />SITE ADDRESS: anJ>1 O � <br />/.I <br />CITY/STATE/ZIP <br />,S <br />CHANGES SITE/OWNER/PERMIT? QEJ <br />FORM A AND/OR B SUBMITTED? <br />NO <br />TANK <br />COMPUTE <br />TANK �j <br />COMPUTER /h�� <br />TANK <br />COMPUTER <br />TANK <br />COMPUTER <br />NUMBER <br />NUMBER �j`"''' <br />S� <br />NUMBER <br />NUMBER <br />TYPE OF INSPECTION <br />SITE COMPUTER # <br />6 / <br />PER # 11)60 <br />PER # <br />PER # <br />PER # <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK TANK CONTENTS <br />/ <br />��'l� `-' r"•~s� i <br />MAJOR MINOR <br />PERMIT TO OPERATE 1 <br />2 <br />CHANGE IN CONDITIONS TO OPERATE 3 <br />4 <br />APPROVED CONSTRUCTION 5 <br />6 <br />WRITTEN MONITORING PROCEDURES 7 <br />8 <br />APPROVED MONITORING SYSTEM 9 <br />10 <br />MONITORING SYSTEM 11 <br />12 <br />APPROVED MONITOR FREQUENCY 13 <br />14 <br />MONITORING RECORDS MAINTAINED 15 <br />16 <br />ACCESS CASING SECURED 17 <br />18 <br />PIPING 19 <br />20 <br />INVENTORY RECONCILIATION 21 <br />2 <br />TANK GAUGING 23 <br />24 <br />APPROVED RESPONSE PLAN 25 <br />26 <br />UNAUTHORIZED RELEASE OCCURRENCE 27 <br />28 <br />SAMPLING 29 <br />30 <br />APPROVED TANK REPAIRS 31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED 33 <br />34 <br />SAFETY HAZARD 35 <br />36 <br />CONDITIONS ABATED <br />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 <br />47 <br />PIPING 48 <br />49 <br />FLAMMABLE VAPORS REMOVED 50 <br />UNAUTHORIZED RELEASE 51 <br />52 <br />SAMPLING 53 <br />54 <br />IMPROPER ABANDONMENT 55 <br />56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS: <br />tic. C.w <br />s <br />57 58 59 <br />MAJOR MINOR NO <br />❑ ❑ <br />VIOL VIOL. VIOL <br />OFFICE' 4 L <br />INSP: <br />RECEIVED BY: / <br />TITLE: Sr. <br />PHONE: <br />RECR <br />HUT -3 White - Original Yellow -Owner's Copy Pink - File Copy 5/88 ©M <br />