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UNRGROUND TANK OFFICIAL INSPECTION R9RT <br /> SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N.San Joaquin Street <br /> Mailing Address: P.O.Box 388 <br /> COUNTY NAME k., Stmkton,468-3420 <br /> 91 0388 COUNTY # <br /> SITE NAME: INSPECTION DATE: - - <br /> SITE ADDRESS: n P /2 �, � !I� /l�G�Y�• CITY/STATE/ZIP T© G A ) C 4�T a <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK J TANK TANK TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> NUMBER NUMBER NUMBER NUMBER <br /> TYPE OF INSPECTION SITE COMPUTER# <br /> PER# PER # PER# PER# <br /> rlo a tf ✓ EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK TANK CONTENTS <br /> MAJOR MINOR d } <br /> 4 <br /> PERMIT TO OPERATE 1 2r'f'r <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 6 <br /> _. -.. . <br /> WRITTEN MONITORING PROCEDURES 7 8 <br /> APPROVED MONITORING SYSTEM 9 10 <br /> MONITORING SYSTEM 11 12 <br /> APPROVED MONITOR FREQUENCY 13 114 <br /> MONITORING RECORDS MAINTAINED 15 16 <br /> ACCESS CASING SECURED 117 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 28 <br /> SAMPLING 29 30 <br /> APPROVED TANK REPAIRS 31 32 <br /> UNAUTHORIZED RELEASES REPORTED 33 34 <br /> SAFETY HAZARD 35 36 <br /> CONDITIONS ABATED 37 <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL 38 39 <br /> FLAMMABLE VAPORS REMOVED 40 <br /> ACCESS LOCATIONS SEALED 41 42 <br /> POWER D$SCONNECTED RMK <br /> OWNER/OPERATOR MONITORING 44 45 <br /> PERMANENT TANK CLOSURE <br /> REMOVAL OF RESIDUAL MATERIALS 46 147 <br /> PIPING 48 149 <br /> FLAMMABLE VAPORS REMOVED 50 VIEMEA <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) FOLLOWS: - { <br /> 57 58 59 <br /> VIOL R ❑ MINVIOLR NO <br /> ❑ VIOL.❑ <br /> OFFICE: INSP:.,/' RECEIVED BY: <br /> TITLE:sr,A t OR. PHONE: RECK: <br /> r, r-T- 1, <br /> HUT-3 White-Original Yellow-Owner's Copy Pink-File Copv 5 a 3 C3 M <br />