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UI`,RGROUND TANK OFFICIAL INSPECTION R SRT <br /> SAN JOAQUIN PUBLIC HEALTH SERVICES '-00 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> COUNTY NAME 445 N San Joaquin Street <br /> Mailing Address: P.O.Box 388 ^ <br /> Stockton,CA 95201-0388 7 <br /> 468-3420 <br /> SITE NAME: COUNTY #11 <br /> faAe q CCI „ INSPECTION DATE: <br /> SITE ADDRESS: <br /> 5000 ;5v_ M a401+ CITY/STATE/ZIP <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK GTd <br /> FORM A AND/OR B SUBMITTED? COMPUTER TANK Z TANK TANK <br /> NUMBER COMPUTER COMPUTER COMPUTER <br /> TYPE OF INSPECTION SITE COMPUTER# NUMBER NUMBER <br /> 01 115 ' PER# PER# NUMBER <br /> J--� PER# PER# <br /> EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK TAMcorrleNis '• / EXP DATE A <br /> PERMIT TO OPERATE <br /> MAJOR MINOR a, .coo <br /> 1 2 <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> MGni <br /> 5 6 <br /> APPROVED CONSTRUCTION l��" ✓ hr�J�d/P�J ✓ <br /> WRITTEN MONITORING PROCEDURES 7 8 t/ - - ✓ ✓ <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 -- - - <br /> 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 38 <br /> CONDITIONS ABATED 37 <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL R44467 <br /> 9 <br /> FLAMMABLE VAPORS REMOVED <br /> ACCESS LOCATIONS SEALED <br /> POWER DISCONNECTED <br /> OWNER/OPERATOR MONITORING <br /> 7T_ <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 /> 59 <br /> MAJOR 57 MINOR NO <br /> VIOL. VIOL. VIOL. <br /> OFFICE: INSP: <br /> TITLE: PHONE: <br /> HUT-3 White-Original Yellow-Owner's Copy Pink-File Copy <br />