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UI- AGROUND TANK OFFICIAL INSPECTION RE IT <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 /> COUNTY NAME Stockton,CA 95201-0388 COUNTY # <br /> 468-3420 <br /> SITE NAME: INSPECTION DATE: <br /> SITE ADDRESS: CITY/STATE/ZIP <br /> CHANGES SITE/O NER/PERMIT? YES NO TANK TANK TANK TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> NUMBER NUMBER NUMBER NUMBER <br /> TYPE OF INSPECTION S►TE COMPUTER* PER A PER J' PER N PER <br /> EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK TANK CONTENTS <br /> MAJOR MINOR ,� n <br /> PERMIT TO OPERATE 1 2 Of <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 6 <br /> WRITTEN MONITORING PROCEDURES 7 8 <br /> APPROVED MONITORING SYSTEM 9 IO <br /> MONITORING SYSTEM 11 12 <br /> APPROVED MONITOR FREQUENCY 13 14 <br /> MONITORING RECORDS MAINTAINED 15 16 <br /> ACCESS CASING SECURED 17 IS <br /> PIPING 19 20 <br /> "JVENTORY 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 REPAIQS 31 32 <br /> UNAUTHORIZED RELEASES REPORTED 33 34 <br /> SAFETY ITAZARD 35 136 <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 DISCONNECTED 43 <br /> OWNER/OPERATOR MONITORING 44 45 <br /> PER TANK CLOSURE 1 + Irk# k 1 1j1 <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 /> 1HE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONE) FOLLOWS:-429 <br /> ------ <br /> 57 58 59 <br /> MAJOR MINOR NO <br /> VIOL. ❑ VIOL, ❑ VOL.__ a�j❑ -- _ __ <br /> OFFICE: INSP RECEIVED BY: <br /> PHONE: REGK: <br /> I IUT-3 White-Original Yellow-Owner's Copy Pink---File Copv <br /> PHS 178 (4/96) <br />