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,I <br /> T i& AGROUND TANK OFFICIAL INSPECTION RT <br />' SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N.San Joacttin Street I' <br /> Mailing Address. P.O.Box 388 <br /> COUNTY NAME StocM aA 5 <br /> CA 90 1-0388 <br /> s COUNTY # i <br /> SITE NAME: INSPECTION DATE: a <br /> SITE ADDRESS: CITY/STATE`/ZIP <br /> CHANGES SITE/OWNER/PERMIT? YES NO TA K TANK, TAN TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> TYPE OF INSPECTION SITE COMPUTER# NUMBER NUMBER NUMBER NUMBER <br /> i <br /> PER # PER#j PER PER# <br /> EXP DATE T EXP.GATE I EXP DATE EXP DATE <br /> TIj <br /> OPER ONAL TANK $UIK CONTENTS Vis" ,z• • , , <br /> MAJOR MINOR '44 ` <br /> PERMIT TO OPERATE 1 2 <br />'i CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 6 I <br /> WRITTEN MONITORING PROCEDURES 7 8 - <br /> APPROVED MONITORING SYSTEM 9 yo <br /> MONITORING SYSTEM 11 12 <br /> APPROVED MONITOR FREOUENCY 13 14 <br /> MONITORING RDS MAINTAINED 16 16 I <br /> ACCESS CASING SECURED 17 yg --- <br /> PIPING _..._. __. <br /> i9 20 . <br /> INVENTORY RECONCILIATION 21 22 It ; <br /> _ ..._. <br /> TANK GAUGING23 24 �a_. <br /> , <br /> APPROVED RESPONSE PLAN 25 i 26 ------ - aE -- -- -- __ ... <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 28 - <br /> SAMPLING 29 30 <br /> I - .. _.._....... .,_ ry <br /> APPROVED TANK REPAIRS 31 32 <br /> UNAUTHORIZED RELEASES REPORTED 33 34 y <br /> SAFETY HAZARD35 136 <br /> f CONDITIONS ABATED 37 <br />` TEMPORARY TANK CLOSURE `R PE <br /> x'a6 ` <br /> REMOVAL OF RESIDUAL 38 39 IF <br /> FLAMMABLE VAPORS REMOVED 40 <br /> A A <br /> ACCESS LOCATIONS SEALED LE 41 42 <br /> POWER DISCONNECTED <br /> OWNER/OPERATOR MONITORING 44 4!3 <br /> PERMANENT TANK CLOSURE <br /> REMOVAL OF RESIDUAL MATERIALS 46 47 ]} <br /> PIPING 48 49 <br /> FLAMMABLE VAPORS REMOVED 5Q <br /> UNAUTHORIZED RELEASE 51 52 <br /> SAMPLING 53 54 i <br /> IMPROPER ABANDONMENT 55 156 <br /> ;i <br /> i <br /> i THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONES FOLLOWS: S F �L <br /> 57 58 59 <br /> VOR MINOR VOIO L IL❑ i; <br /> '4 <br /> r <br /> 'I4 k <br /> 17 <br /> OFFICE: INSP RECEIVED BY: <br /> J ' <br /> TITLE. PHONE: RECK: <br /> I W_4�s_ I{ 11 <br /> HUT-3 White-Oricinal Yellow-Owners Cagy Pink-gile <br />