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COUNTY NAME <br />SITE 'NAME: �, s <br />SITE ADDRESS: <br />*RGROUND TANK OFFICIAL INSPECTION nib RT <br />SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 E. Weber Ave., Third Floor <br />Mailing Address: P.O. Box 388 <br />Stockton, CA 95201-0388 COUNTY # <br />468-3420 <br />INSPECTION DATE: <br />CITY/STATE/ZIP <br />CHANGES SITE/OWNER/PERMIT? YES NO <br />FORM A AND/OR B SUBMITTED? <br />T <br />COMPUTER <br />NUMBER <br />PER of <br />EXP. DATE <br />TANK <br />COMPUTER <br />NUMBER <br />PER # <br />EXP. DATE <br />TANK <br />COMPUTER <br />NUMBER <br />PER # <br />EXP. DATE <br />NJ <br />TANK <br />COMPUTER <br />NUMBER <br />PER # <br />EXP. DATE <br />TYPE OF INSPECTION <br />tit T`i <br />SITE COMPUTER # <br />OPERATIONAL TANK <br />PERMIT TO OPERATE <br />CHANGE IN CONDITIONS TO OPERATE <br />APPROVED CONSTRUCTION <br />WRITTEN MONITORING PROCEDURES <br />APPROVED MONITORING SYSIEM <br />MONITORING SYS IEM <br />APPROVED MONITOR FREQUENCY <br />MONITORING RECORDS MAINTAINED <br />ACCESS CASING SECURED <br />PIPING <br />`NVENTORY RECONCILIATION <br />TANK GAUGING <br />APPROVED RESPONSE PLAN <br />UNAUTHORIZED RELEASE OCCURRENCE <br />SAMPLING <br />APPROVED TANK REPAIRS <br />UNAUTHORIZED RELEASES REPORTED <br />SAFETY I IAZARD <br />CONDITIONS ABATED <br />LANK CONIEHTS <br />MAJOR <br />1 <br />3 <br />MINORVMS <br />2 <br />4i <br />1 a'. <br />` <br />/ <br />Vf <br />51 <br />-54 <br />f <br />SAMPLING <br />5 <br />6 <br />7 <br />9 <br />8 <br />IU <br />12 <br />11 <br />13 <br />14 <br />15 <br />16 <br />17 <br />116 <br />19 <br />20 <br />21 <br />22 <br />23 <br />24 <br />25 <br />26 <br />27 <br />28 <br />29 <br />30 <br />31 <br />32 <br />33 <br />34 <br />35 136 <br />37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />46 47 <br />PIPING <br />48 <br />49 <br />FLAMMABLE VAPORS REMOVED <br />50 <br />.E <br />UNAUTHORIZED RELEASE <br />51 <br />52 <br />SAMPLING <br />53 <br />54 <br />IMPROPER ABANDONMENT <br />55 <br />156 <br />SYSTEM STATUS (MUSE MARK ONE► <br />57 58 <br />59 <br />MXIOVIOL. R [j MINOR <br />[j NO <br />❑ <br />VOL. <br />OFFICE <br />INS <br />I I TITLE: VE <br />TT <br />I IUT-3 White - Original Yellow - owner's Copy Pink - File Cap" <br />It IE MARKED HEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />FOLLOWS: -S_ --- <br />RECKIVED BY: <br />BECK: <br />PHS 178 (4796) 1 <br />