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I iGROUND TANK OFFICIAL INSPECTION R RT <br />SAN JiOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N. San Joaquin Street <br />Mailing Address: P.O. Box 388 <br />COUNTY NAME Stockton, CA 95201-0388 COUNTY # <br />ARR-14;)n <br />SITE NAME: �%f /LXX i <br />INSPECTION DATE: <br />1 <br />(s [jj <br />✓/ j <br />SITE ADDRESS:V,46,al6`0 <br />/STATE/ <br />CHANGES SITE/OWNER/PERMIT? YES <br />FORM A AND/OR 8 SUBMITTED? <br />NO <br />TANK <br />COMPUTFK3 <br />NUMBER iG <br />PER /1 <br />EXP. D - <br />/ <br />TANK <br />COMPUTER <br />NUMBER <br />PER N <br />EXP. DATE <br />TANK <br />COMP R <br />NUMBER <br />PER <br />EXP. DATE <br />TANK <br />COMPUTER <br />NUMBER <br />PER <br />EXP. DATE <br />TYPE OF INSP CTION,, / <br />/SCJ �Y! <br />SITE COMPUTER <br />�/ <br />OPERATIONAL TANK <br />TANKCONTENTs <br />MAJOR MINOR <br />PERMIT TO OPERATE <br />1 <br />2 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 <br />4 <br />APPROVED CONSTRUCTION <br />5 <br />6 <br />WRITTEN MONITORING PROCEDURES <br />7 <br />8 <br />APPROVED MONITORING SYSTEM <br />9 <br />10 <br />MONITORING SYSTEM <br />11 <br />12 <br />APPROVED MONITOR FREQUENCY <br />13 <br />14 <br />MONITORING RECORDS MAINTAINED <br />15 <br />116 <br />ACCESS CASING SECURED <br />17 <br />118 <br />PIPING <br />19 <br />120 <br />INVENTORY RECONCILIATION <br />21 <br />22 <br />TANK GAUGING <br />23 <br />24 <br />APPROVED RESPONSE PLAN <br />25 <br />26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 <br />28 <br />SAMPLING <br />29 <br />30 <br />APPROVED TANK REPAIRS <br />31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 <br />34 <br />SAFETY HAZARD <br />35 <br />36 <br />CONDITIONS ABATED <br />37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />38 <br />39 <br />FLAMMABLE VAPORS REMOVED <br />4U <br />ACCESS LOCATIONS SEALED <br />41 <br />42 <br />POWER DISCONNECTED <br />43 <br />OWNER/OPERATOR MONITORING <br />4 <br />445 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />46 <br />47 <br />— <br />PIPING <br />48 <br />49 <br />FLAMMABLE VAPORS REMOVED <br />50 <br />UNAUTHORIZED RELEASE <br />51 <br />52 <br />SAMPLING <br />53 <br />54 <br />IMPROPER ABANDONMENT <br />55 <br />56 <br />TFIE MARKED ITEMS REPRESENT VI LATIONS AND MUST BE. CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS- <br />57 58 <br />_ <br />— . . <br />MAJOR MINOR NO` <br />VIOL <br />VIOL VIOL. <br />OFFICE: <br />INSP <br />RECEIVED BY: <br />TITLE: <br />j7 <br />r" <br />PHONE:. , <br />C1 <br />BECK: <br />� ,�fJ 21 <br />Owner's Copy Pink - File Copy '/88 C7 µ <br />