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U. AGROUND TANK OFFICIAL INSPECTION RL 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: 1112 <br /> SITE ADDRESS: t CITY/STATE/ZIP <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK TANK TANK i <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> TY E OF INSPECTION SITE COMPUTER / NUMBER NUMBER NUMBER NUMBER <br /> • <br /> PER+I PER* PER PER * <br /> EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK TAM CONTENTS <br /> MAJOR MINOR Ica <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 IU <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 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 REPAIIIS 31 32 <br /> UNAUTHORIZED RELEASES REPORTED 33 134 <br /> SAFETY I IAZARD 6E37 <br /> 36 <br /> CONDITIONS ABATED <br /> TEMPORARY TANK CLOSURE Hw4m' <br /> xd� .1�, <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 /> �� •�gp��.4r Via:.�� �.� is�+.I��y:, I Ir� �yl �. dr .. � ,.-: , <br /> PERMANENT TANK CLOSURE 4 � �Tr, � iC..: <br /> 1,. .� ,l+ <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 VIOLATI_gNS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUSE MARK ONE) FOLLOWS: SET--� —��_ --- --- <br /> �o°R a MINOR <br /> o NO <br /> 59 o _ — — — --- - -- <br /> OFFICE: INSP. I RECEIVE <br /> TITLE PHONE: BECK: <br /> I-IUT-3 White-Original Yellow-Owner's Copy Pink-File Copv <br /> PHS 178 (4/96) <br />