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Uh"ERGROUND TANK OFFICIAL INSPECTION RL -WORT <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 Stockton, CA 95201-0388 COUNTY # <br />488-3420 <br />SITE NAME: - - <br />INSPECTION DATE: <br />� G <br />, <br />SITE ADDRESS: c5��z v7G,7-oR <br />CITY/STATE/ZIPlp�//� <br />CHANGES SITE <br />YES <br />Nli <br />TANK Al! / <br />TANK #Z- <br />TANK A-`Tj <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER jLK <br />NUMBER <br />COMPUTER/OK <br />NUMBER <br />COMPUTERS <br />NUMBER <br />COMPUTER <br />NUMBER <br />TYPE OF INSPECTION <br />SITE COMPUTER # <br />PER # <br />PER # <br />PER # <br />PER # <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />TWK col ( lm <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 />16 <br />ACCESS CASING SECURED <br />17 <br />18 <br />PIPING <br />19 <br />20 <br />INVENTORY RECONCILIATION <br />TANK GAUGING <br />23 <br />124 <br />APPROVED RESPONSE PLAN <br />25 <br />26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 <br />28 <br />~� w <br />SAMPLING <br />29 <br />30 <br />APPROVED TANK REPAIRS <br />31 <br />32 <br />_ <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 />- <br />REMOVAL OF RESIDUAL <br />38 <br />39 <br />FLAMMABLE VAPORS REMOVED <br />40 <br />ACCESS LOCATIONS SEALED <br />41 <br />42 <br />POWER DISCONNECTED <br />mm <br />43 <br />OWNER/OPERATOR MONITORING <br />44 <br />45 <br />ERMANENT-TANK-CLOSURE---, <br />REMOVAL OF DUAtMATEROILS�- <br />46 <br />47 <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 />SYSTEM STATUS (MUST MARK ONE) <br />THE MARKED ITEMS REPRESENT/ VIOLATIONS AND MUST BE CORRECTED AS <br />*!IF <br />FOLLOWS: <br />57 58 <br />59 <br />❑ ❑ <br />❑ <br />VIOLOR VIOLO.R <br />VIOL. <br />OFFICE: <br />INSP: <br />RECEIVED BY: <br />/ <br />TITLE: le, <br />� fjls <br />PHONE: <br />RECK: <br />HUT -3 White - Original Yellow - Owner's Copy Pink - File Copy sine C'.. <br />