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UPTERGROUND TANK OFFICIAL INSPECTION R9lf0RT <br />SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N. San Joaquin Street <br />Mailing Address: P.O. Boz 388 <br />COUNTY NAME F1 rx ri �� Stockton, CA 95201-0388 noNury y e!;) <br />- - <br />- <br />415a -J4213 <br />uuum 1 %J <br />7 <br />SITE NAME: U� ✓ v <br />INSPECTION DATE: <br />3 <br />SITE ADDRESS: 3 7 75 'rO tl <br />CITY/STATE/ZIP <br />-rR,4C y <br />C /9 - <br />CHANGES SITE/OWNER/PERMIT? <br />YES <br />NO TANK S <br />TANK <br />TANK 7 <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />(/p <br />COMPUTER <br />COMPUTER <br />TYPE OF INSPECT +N $ITE COMPUTER <br />F YI t <br /># <br />NUMBER <br />PER # <br />NUMBER <br />NUMBER <br />COMPUTER <br />NUMBER <br />I ++`b ]"i <br />I . <br />9 <br />PER # <br />PER # <br />PER # <br />01 <br />OPERATIONAL TANK <br />EXP DATE <br />TANK OON NM <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />PERMIT TO OPERATE <br />MAJOR MINOR <br />1 2 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 <br />4 <br />/, L <br />it <br />APPROVED CONSTRUCTION <br />5 <br />6 <br />WRITTEN MONITORING PROCEDURES <br />7 <br />8 ✓ <br />V/ <br />/ <br />APPROVED MONITORING SYSTEM <br />9 <br />10 <br />V <br />MONITORING SYSTEM <br />11 <br />12 <br />APPROVED MONITOR FREQUENCY <br />13 <br />14 <br />MONITORING RECORDS MAINTAINED <br />15 <br />16 <br />ACCESS CASING SECURED <br />17 <br />18 <br />PIPING V e )j -t1 %-)A Por <br />19 <br />20 <br />INVENTORY RECONCILIATION <br />21 <br />22 <br />TANK GAUGING <br />APPROVED RESPONSE PLAN <br />23 <br />25 <br />24 <br />26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 <br />28 <br />SAMPLING <br />29 <br />30 _._. ... <br />.... _.__. <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 />PRt: c ;s cam- Test rg <br />37 <br />TEMPORARY TANK CLOSURE <br />mom <br />?D <br />REMOVAL OF RESIDUAL <br />38 <br />3g <br />FLAMMABLE VAPORS REMOVED <br />40 <br />7 <br />ACCESS LOCATIONS SEALED <br />41 <br />42 <br />POWER DISCONNECTED <br />43 <br />OWNER/OPERATOR MONITORING <br />44 <br />45 <br />PERMANENT TANK CLOSURE' <br />.:. <br />REMOVAL OF RESIDUAL MATERIALS <br />46 <br />... <br />47 <br />... <br />'s .` <br />PIPING <br />48 <br />49 <br />FLAMMABLE VAPORS REMOVED <br />50ME <br />UNAUTHORIZED RELEASE <br />51 <br />52 <br />SAMPLING <br />53 <br />54 <br />IMPROPER ABANDONMENT <br />55 <br />56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS: <br />57 58 <br />59 <br />MAJOR MINOR NO <br />- i ❑ <br />❑ <br />_ <br />VIOL. 1 VIOL. VIOL. <br />OFFICE: <br />INSP: <br />. <br />RE VED BY: <br />o �/ <br />TITLE: -S� cE \ % fT J <br />PHONE: RECK <br />nu —3 Ta ww - towner s copy Ylnk - File Cepv <br />