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Use,,;RGROUND TANK OFFICIAL INSPECTION RL.'ORT SAN JOAQUIN PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N.San Joaquin Street Mailing Address: P.O.Box 388 ii Stookto 488 3420 1 0388 COUNTY # Ja COUNTY NAME Sd Vt kJ INSPECTION DATE: SITE NAME: �l\ �- G � H�_ KO /�. 7 ' J� C y U CITY/STATE/ZIP -T�14 C y SITE ADDRESS: 3 I CHANGES SITE/OWNER/PERMIT? YES NO TANK l TANK TANK 3 TANK FORMA AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER NUMBER NUMBER NUMBER NUMBER TYPE OF INSPECTION SITE COMPUTER�# PER# PER # PER # PER# TANK Rr—A c%AL 3 t z ' IF EXP.DATE EXP.DATE EXP.DATE EXP.DATE TANK COM NTS -$}, OPERATIONAL TANK MAJOR MINOR �' R'? PERMIT TO OPERATE 1 2 CHANGE IN CONDITIONS TO OPERATE 3 4 APPROVED CONSTRUCTION 5 6 WRITTEN MONITORING PROCEDURES 7 8 / C6'C4��— 000 r )j00 APPROVED MONITORING SYSTEM 9 10 r ,1'+ IR$S r B$� r SS FI 0,& 45_� MONITORING SYSTEM 11 12 / APPROVED MONITOR FREQUENCY 13 14 MONITORING RECORDS MAINTAINED 15 16 ACCESS CASING SECURED 17 18 PIPING 19 20 INVENTORY RECONCILIATION 21 22 TANK GAUGING 23 24 APPROVED RESPONSE PLAN 25 26 UNAUTHORIZED RELEASE OCCURRENCE 27 28 SAMPLING 29 30 _... APPROVED TANK REPAIRS 31 32 UNAUTHORIZED RELEASES REPORTED 33 34 SAFETY HAZARD 35 36 CONDITIONS ABATED 37 TEMPORARY TANK CLOSURE X� REMOVAL OF RESIDUAL 38 39 FLAMMABLE VAPORS REMOVED 40 ACCESS LOCATIONS SEALED 41 42 POWER DISCONNECTED 43 OWNER/OPERATOR MONITORING 44 45 PERMANENT TANK CLOSURE r REMOVAL OF RESIDUAL MATERIALS 46 47 PIPING 48 49 FLAMMABLE VAPORS REMOVED 50 UNAUTHORIZED RELEASE 51 52 SAMPLING 53 54 IMPROPER ABANDONMENT 55 56 YSTEM STATUS(MUST MARK ONE) THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS S FOLLOWS- 5758 59 r nkMAJOR MIN VIOL. ❑ VIOLO.R ❑ VIOL.❑ - OFFICE: INSP: S RECEIVED BY: TITLE:,SiN/OR- RENS PHONE PECK HUT-3 White-Oricinal Yellow-Owner's Copy Pink-Filo Copy