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T ' <br /> L&RGROUND TANK OFFICIAL INSPECTION&RT <br /> SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N.San Joaquin Street <br /> Addess: P.O.Box <br /> COUNTY NAME Mailing <br /> StooktonrCA95201-0388388 <br /> 201038888 <br /> COUNTY <br /> 488.3420 '# <br /> SITE NAME: �?� ( / INSPECTION DATE: <br /> SITE ADDRESS: O OA K —5--f �! CITY/STATE/ZIP <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK 0( 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 /> Rom I9 PER# PER # PER# PER# <br /> /1/,� EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK TANKCONreNTS <br /> MAJOR MINOR <br /> PERMIT TO OPERATE 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 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 P43 <br /> FLAMMABLE VAPORS REMOVED <br /> ACCESS LOCATIONS SEALED <br /> POWER DISCONNECTED 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: <br /> 57 58 59 - -- <br /> MAJOR �y MINOR NO <br /> VIOL LI VIOL. ❑ VIOL❑ <br /> OFFICE: INSP: RECEIVED B <br /> 4 <br /> , <br /> TITLE: PHONE: 8- RECK: <br /> X 33 <br /> HUT-3 White-Original Yellow-Owner's Copy Pink-File Copv 5iea CJ M <br />