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OERGROUND TANK OFFICIAL INSPECTION *RT <br /> SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 306 E.Weber Ave.,Third Floor <br /> Mailing Address:P.O.Boz 380 <br /> COUNTY NAME Stockton,CA 95201-0388 COUNTY # <br /> 468-3420 <br /> SITE NAME: INSPECTION DATE: <br /> SITE ADDRESS: CITY/STATE/ZIP <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK TANK TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> TYPE OF INSPECTION SITE COMPUTER# NUMBER NUMBER NUMBER NUMBER <br /> PER # PER# PER # PER # <br /> G EXP.DAZE EXP.DATE EXP.DATE EXP.DATE <br /> OPE ATIONALTANK TANK coWENT9 ,tib;).. i ".yP��1 t rri8"11]�Ifl <br /> MAJOR MINOR l II t 'y <br /> PERMIT 70 OPERATE 1 2 <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 6 <br /> WRITTEN MONITORING PROCEDURES 7 8 <br /> APPROVED MONITORING SYSTEM 9 10 <br /> MONITORING SYSTEM I 1 12 <br /> APPROVED MONITOR FREQUENCY 13 14 <br /> MONITORING RECORDS MAINTAINED 15 16 <br /> ACCESS CASING SECURED 17 18 <br /> PIPING 19 20 <br /> INVENTORY RECONCILIATION 21 22 <br /> TANK GAUGING 23 24 <br /> APPROVED RESPONSE PLAN 25 26 <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 13 <br /> SAMPLING 29 30 <br /> APPROVED TANK REPAIRS 31 32 <br /> UNAUTHORIZED RELEASES REPORTED 33 34 <br /> SAFETY I IAZARD 35 36 <br /> CONDITIONS ABATED 37 ,. <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL W4445 <br /> FLAMMABLE VAPORS REMOVED <br /> ACCESS LOCATIONS SEALED <br /> POWER DISCONNECTED <br /> OWNER/OPERATOR MONITORING <br /> r �! `"ilfl�NJ x rel ' L ;- •-i <br /> PERMANENT TANK CLOSURE NAVA, p{ <br /> 17 <br /> REMOVAL OF RESIDUAL MATERIALS 46 47 <br /> PIPING 48 49 <br /> FLAMMABLE VAPORS REMOVED 50 <br /> UNAUTHORIZED RELEASE 51 52 <br /> SAMPLING 53 54 <br /> IMPROPER ABANDONMENT 55 56 <br /> THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONE) FOL OWS:I.FEIe '1"��ToJt`�4.//sl <br /> 1 <br /> 57 58 59 <br /> MAJOR El VIOL.VIOL. ❑ NO <br /> VOL.❑ i ___— <br /> �,14G _ <br /> OFFICE: INS RECEIVED BY: <br /> TITLE: I 1 PHONE: HECK <br /> MUT-3 While-Original Yellow-Owner's Copy Pink File Copv <br /> PHS 178 (4196) <br />