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U :RGROUND TANK OFFICIAL INSPECTION V JRT <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 Stockton, CA 95201-0388 COIINTY # <br />SITE NAME: o� ,�� <br />��,� ��.1-�,e. <br />INSPECTION DATE:o"::--tea= <br />SITE ADDRESS: 137 / <br />L��� <br />CITY/STATE/ZIP <br />CHANGES SITE <br />YES <br />NO <br />TANK <br />TANK <br />TANK i 7 <br />TANK -�8 <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />NUMBER <br />li/i/i <br />COMPUTER <br />NUMBER W�d <br />COMPUTER <br />NUMBER <br />PSL <br />COMPUTER <br />NUMBER <br />TYPE OF INSPECTION77z <br /># <br />o nA E <br />Z <br />PER # <br />PER # <br />PER # <br />PER # <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />TANK CONTENTS <br />MAJOR MINOR <br />r <br />PERMIT TO OPERATE <br />1 <br />2 x <br />( <br />x <br />x y <br />/` <br />CHANGE IN CONDITIONS TO OPERATE <br />3 <br />4 <br />APPROVED CONSTRUCTION <br />5 <br />6 <br />WRITTEN MONITORING PROCEDURES <br />7 <br />8 _IX <br />IK <br />x <br />APPROVED MONITORING SYSTEM <br />10 <br />./ <br />MONITORING SYSTEM <br />11 <br />12 <br />APPROVED MONITOR FREQUENCY <br />14 x <br />x X <br />MONITORING RECORDS MAINTAINED <br />15 <br />16 <br />ACCESS CASING SECURED <br />17 <br />18 <br />PIPING <br />19 <br />20 <br />INVENTORY RECONCILIATION <br />21 <br />22 <br />TANK GAUGING <br />23 <br />24 <br />APPROVED RESPONSE PLAN <br />26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 <br />28 <br />SAMPLING <br />29 <br />30 <br />APPROVED TANK REPAIRS <br />31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 <br />34 <br />SAFETY HAZARD <br />135 <br />136 <br />CONDITIONS ABATED <br />37 VA <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />38 <br />139 <br />FLAMMABLE VAPORS REMOVED <br />40 <br />WMEA <br />ACCESS LOCATIONS SEALED <br />41 <br />42 <br />POWER DISCONNECTED <br />M <br />43 <br />OWNER/OPERATOR MONITORING <br />44 <br />45 <br />PERMANENT TANK CLOSURE <br />177 —47 <br />t` <br />REMOVAL OF RESIDUAL MATERIALS <br />46 <br />147 <br />PIPING <br />48 <br />149 <br />FLAMMABLE VAPORS REMOVED <br />50 <br />UNAUTHORIZED RELEASE <br />51 <br />52 <br />SAMPLING <br />53 <br />54 <br />IMPROPER ABANDONMENT <br />55 <br />56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS: <br />57 58 <br />59 <br />MAJOR MINOR NO <br />❑ <br />❑ <br />VIOL. VIOL. VIOL. <br />OFFICE: <br />RECEIVED BY�4o/.,,_Q <br />TITLE: <br />E 7t/. s. <br />PH ONE <br />BECK: <br />)�=o�3?j <br />HUT -3 White - Original Yellow - Owner's Copy Pink - File Ccpv � -, M <br />