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U%rERGROUND TANK OFFICIAL INSPECTION F�ORT <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 />488-3420 <br />SITE NAME: <br />INSPECTION DATE: zA 9 <br />S A O S <br />SITE ADDRESS: lZZ Lp� <br />CITY/STATE/ZIP <br />CHANGES SITE YES <br />NO <br />TANK / <br />TANK Z— <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />COMPUTER <br />COMPUTE <br />COMPUTER <br />NUMBER <br />NUMBER <br />NUMBER <br />NUMBER <br />TYPE OF INSPECTION <br />SITE COMPUTER # <br />�j L <br />Z600 <br />PER # <br />PER # <br />PER # <br />PER # <br />O <br />EXP DATE <br />EXP_DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK mRx coRleNTs <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 />22 <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 MF <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 <br />56 �� <br />,/ ✓ <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS: SEA'—� PAGc.T V <br />MAJOVIOL.R <br />MINOR Li <br />od' <br />VI IJ VIOL VOL. <br />OFFICE <br />RECEIVED BY:,,4fdp74,I!F4 Te: Z 6L vAi54- <br />/ <br />A sr. <br />Lo4v1 41,5 -pen, <br />TITLE: <br />PHONE: <br />X68= <br />RECK: <br />HUT -3 White - Original Yellow - Owner's Copy Pink - File Copy siva 0M <br />