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AGROUND TANK OFFICIAL INSPECTION RAIT <br />SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N. San Joaquin Street <br />Mailing Address: P.O. Box 388 <br />COUNTY NAME Stockton, CA 95201-0388 <br />'E� A 2111 <br />468-3420COUNTY <br />FSIT7ENAME-' INSPECTION DATE:t�Zy) <br />SITE ADDRESS: CITY/STATE/ZIP <br />3HANGES SITE/OWNER/PERMIT? YES NO <br />:ORM A AND/OR B SUBMITTED? <br />TANK <br />COMPUTE <br />NUMBER <br />TANK 7' <br />COMPUTER <br />NUMBER <br />TANK <br />COMPUTER <br />NUMBER <br />TANK <br />COMPUTER <br />NUMBER <br />TYPE OF INSPECTION <br />SITE COMPUTER # <br />7-0 <br />PER # <br />EXP. DATE <br />PER # <br />EXP. DATE <br />PER # <br />EXP. DATE <br />PER # <br />EXP. DATE <br />OPERON <br />ATIA TANK <br />PERMIT TO OPERATE <br />TANK CONTENTS <br />MAJOR MINOR <br />1 2 <br />40 <br />aw <br />IMPROPER ABANDONMENT 155 56 <br />ACCESS LOCATIONS SEALED <br />41 <br />CHANGE IN CONDITIONS TO OPERATE <br />)YSTEM STATUS (MUST MARK ONE) <br />POWER DISCONNECTED <br />m <br />3 4 <br />APPROVED CONSTRUCTION <br />5 6 <br />OWNER/OPERATOR MONITORING <br />44 <br />45 <br />WRITTEN MONITORING PROCEDURES <br />7 8 <br />APPROVED MONITORING SYSTEM <br />9 10 <br />MONITORING SYSTEM <br />11 12 <br />APPROVED MONITOR FREQUENCY <br />13 14 <br />MONITORING RECORDS MAINTAINED <br />15 16 <br />ACCESS CASING SECURED <br />17 18 <br />PIPING <br />19 20 <br />INVENTORY RECONCILIATION <br />21 22 <br />TANK GAUGING <br />23 24 <br />APPROVED RESPONSE PLAN <br />25 26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 28 <br />SAMPLING <br />29 30 <br />APPROVED TANK REPAIRS <br />31 32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 34 <br />SAFETY HAZARD <br />35 36 <br />CONDITIONS ABATED <br />.. .... . <br />W/' , 37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS 46 47 <br />PIPING 48 49 <br />01" <br />REMOVAL OF RESIDUAL <br />38 <br />39 <br />FLAMMABLE VAPORS REMOVED <br />40 <br />IMPROPER ABANDONMENT 155 56 <br />ACCESS LOCATIONS SEALED <br />41 <br />42 <br />)YSTEM STATUS (MUST MARK ONE) <br />POWER DISCONNECTED <br />m <br />43 <br />OWNER/OPERATOR MONITORING <br />44 <br />45 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS 46 47 <br />PIPING 48 49 <br />FLAMMABLE VAPORS REMOVED 50 m <br />UNAUTHORIZED RELEASE 51 52 <br />SAMPLING 153 154 <br />IMPROPER ABANDONMENT 155 56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />FOLLOWS ca, ca, A- A--� <br />)YSTEM STATUS (MUST MARK ONE) <br />MAJOR 57 MINOR 58 NO r59 <br />-A <br />VIOL. VIOL. ❑ VIOL. EJ <br />OFFICE: <br />6 6 <br />sm <br />wmmwjw.Z�,-"%�' <br />MAI <br />a 61 <br />PHONE: <br />11*904 <br />