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L —:RGROUND TANK OFFICIAL INSPECTION R. RT <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: ct� INSPECTION DATE: / L <br /> SITE ADDRESS: -7 CITY/STATE/ZIP <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK �5 p TANK /Z-IC TANK TANK r K <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER e(j COMPUTER rl 'J COMPUTER 11_d <br /> NUMBER NUMBER NUMBER NUMBER <br /> TYPE OF INSPECTION SITE COMPUTER# PER # PER* PER # PER <br /> EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK TANK CONTENTS <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 <br /> APPROVED MONITORING SYSTEM 9 10 <br /> MONI TORING SYSTEM 11 112 <br /> APPROVED MONITOR FREQUENCY 13 114 <br /> MONITORING RECORDS MAINTAINED 115 116 <br /> ACCESS CASING SECURED 17 18 <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 /> APPROVED TANK REPAIRS 31 32 <br /> UNAUTHORIZED RELEASES REPORTED 33 34 <br /> SAFETY IIAZARD 35 36 <br /> CONDITIONS ABATED 37 <br /> TEMPORARY TANK CLOSURE to,I MR <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 /> PERMANENT TANK CLOSURE rsTy � <br /> 4n <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 55 156 <br /> THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUSr MARK ONE) FOLLOWS: <br /> MAJOR 57 MINOR 58 NO 59 - ---— ------ <br /> VIOL. ❑ VIOL. ❑ VIOL. <br /> OFFICE: INSP: �1� RECEIVE B <br /> TITLE: /�� PHONE: BECK: <br /> (00-1) y6 �o33�� <br /> 1-IUT-3 White-Original Yellow-Owner's Copy Pink-File Copy <br /> PHS 178 (4/96) <br />