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UA.iRGROUND TANK OFFICIAL INSPECTION R"RT <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: INSPECTION DATE: <br /> SITE ADDRESS: / -a tz,;, IF, , 1 8� CITY/STATE/ZIP a+()CO I <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 /> Rv EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK WIK001' N'S <br /> MAJOR MINOR <br /> PERMIT TO OPERATE 1 2 <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 6 <br /> WRITTEN MONITORING PROCEDURES 7 8 .f <br /> APPROVED MONITORING SYSTEM 9 10 <br /> MONITORING SYSTEM 11 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 1� <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 28 <br /> _._ <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 W43 <br /> 9 -- <br /> FLAMMABLE VAPORS REMOVED <br /> ACCESS LOCATIONS SEALED 2 <br /> POWER DISCONNECTED OWNER/OPERATOR MONITORING 5 <br /> PERMANENT TANK CLOSURE <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) FOLLOWS: <br /> MAJOR 57 MINOR 58 59 ok n <br /> VIOL. ❑ VIOL. ❑ VOL.❑ <br /> OFFICE: IN r ;RECEIVEED:BY:c�TITLEO3? RECK: <br /> HUT-3 White-Original Yellow-Owner's Copy Pink-File Copy 5/m OM <br />