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U PERGROUND TANK 01=FICIAL INSPECTION R*RT SAN JOAQUIN PUBLIC HEALTH SERVICES ENVIRONMENTALHE HEALTH DIVISION E. Third Mailing Address:P.O.Box 388 COUNTY NAME stockto95201-0388_ COUNTY # 468-3420 SITE NAME: INSPECTION DATE: f SITE ADDRESS: CITY/STATE/ZIP CHANGES SITE/OWNER/PERMIT? YES NO "TANK TANK TANK TANK FORM AAND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER NUMBER NUMBER NUMBER NUMBER TYPE OF INSPECTION SITE COMPUTER 4 PER PER 4 PER if PER # EXP.DATE EXP.DATE}} EXP.DATE EXP.DATE TANK CONIENTS .r OPERATIONAL TANK ! }i, MAJOR MItdQR PERMIT TO OPERATE I 2 CHANGE IN CONDITIONS TO OPERATE 3 APPROVED CONSTRUCTION 5 6 WRITTEN MONITORING PROCEDURES 7 d APPROVED MONITORING SYS IEM 9 10 MONITORING SYS I EM 11 12 APPROVED MONITOR FREQUENCY 13 14 MONITORING RECORDS MAINTAINED 15 16 ACCESS CASING SECURED 17 16 PIPING 19 20 ,NVENTORY RECONCILIATION 21 22 'TANK GAUGING 23 24 APPROVED RESPONSE PLAN 25 26 UNAUTHORIZED RELEASE OCCURRENCE 27 26 SAMPLING 29 30 APPROVED TANK REPAIRS 31 32 � UNAUTHORIZED RELEASES REPORTED 33 34 SAFETY I IAZARD 35 36 CONDITIONS ABAIED 37 TEMPORARY TANK CLOSURE � ' , , REMOVAL OF RESIDUAL 3B 39 FLAMMABLE VAPORS REMOVED 40 ACCESS LOCATIONS SEALED 41 42 POWER DISCONNECTED 43 OWNER/OPERATOR MONITORING 44 45 qg PERMANENT TANK CLOSURE REMOVAL OF RESIDUAL MATERIALS 46 47 PIPING 48 49 FLAMMABLE VAPORS REMOVED 50 ME UNAUTHORIZED RELEASE 51 52 SAMPLING 53 54 IMPROPER ABANDONMENT 55 56 THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS SYSTEM STATUS}MUST MARK ONE1 —___—_ --- ----- FOLLOWS: MAJOR 57 MINOR B NO 9 - VIOL VIOL. LJ VIOL.Ll _ — - OFFICE: INSP: I REC/E)VED, ,BY/: J /� TIT LE: PHONE: BECK I IUT-3 While-Original Yellow-Owner's Copy Pink-File Copy PHS 178 (4196)