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II UNC. ,GROUND TANK OFFICIAL INSPECTION REI( r <br /> • SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 E. Weber Ave.. Third Floor <br /> 1 Mailing Address: P.O. Box 366 <br /> COUNTY NAME SaN#W J6 Q Stockton, CA 95201 -WHCOUNTY # 3 <br /> 466-3420 <br /> SITE NAME: S JS I � „ q(_ _ - P INSPECTION DATE: <br /> SITE ADDRESS: /3 0 / U W TNI n 0i CITY /STATE /ZIP s f©G`r7' n1 <br /> CHANGES SITE /OWNER/ PERMIT? YES NO TANK TANK TANK TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> NUMBER NUMBER NUMBER NUMBER <br /> r0i�IFIWATTO'NAL <br /> PE OF INSPECTION O SITE COMPUT T PER N PER Or PER # PER .! <br /> Pr G�� '' S V EXP. DATE EXP. DATE EXP. DATE EXP. DATE <br /> TANK C "I <br /> TANK MAJOR MINOR4 IF <br /> ., > <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 <br /> APPROVED MONITORING SYSTEM 9 10 <br /> MONITORING SYSTEM I I 12 <br /> APPROVED MONITOR FREQUENCY 13 14 <br /> MONITORING RECORDS MAINTAINED 15 16 <br /> ACCESS CASING SECURED 17 IB <br /> PIPING 19 20 <br /> ,NVENTORY 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 /> IF <br /> APPROVED TANK REPAIINIS 31 32 <br /> UNAUTHORIZED RELEASES REPORTED <br /> SAFETY 1-IAZARD 35 36 <br /> CONDITIONS ABATED 37 <br /> A 1 ! e <br /> TEMPORARY TANK CLOSURE F3 Y k * ! '< <br /> . r' } <br /> REMOVAL OF RESIDUAL` 38 39 <br /> FLAMMABLE VAPORS REMOVED 40 <br /> ACCESS LOCATIONS SEALED 4 1 A2 <br /> POWER DISCONNECTED A3 <br /> OWNER/OPERATOR MONITORING 44 45 <br /> k it <br /> PERMANENT TANK CLOSUREg , Y4, TFlft n r f fll4 ` a tF 'j1 1 <br /> 4 <br /> REMOVAL OF RESIDUAL MATERIALS A6 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 IMUSF MARK ONE) FOLL S: <br /> C <br /> VIOL MAJOR MIN1:1 VIOL. ❑ VIOL. ❑ - <br /> OFFICE: INS �v {3r ' s RECEIVED BY: <br /> TITLE: Sri T E. H 5o PHONE: BECK: <br /> HUT-3 While - Original Yellow - Owner's Copy Pink - File Copy <br /> PHS 178 (9/96) <br />