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AGROUND TANK OFFICIAL INSPECTION R RT <br />SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N. San Joaquin Street <br />ing Addess: P.O. Box <br />COUNTY NAME MailStockton,rCA 95201-0388388 <br />468-3420 COUNTY # <br />SITE NAME: INSPECTION DATE: <br />1-5 — i�-- <br />SITE ADDRESS: CITY/STATE/ZIP <br />CHANGES SITE/OWNER/PERMIT? YES NO <br />TANK 0/ <br />TANK p2 <br />TANK 6>3 <br />TANK a> <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />NUMBER <br />COMPUTER <br />NUMBER <br />COMPUTER <br />NUMBER <br />COMPUTER <br />NUMBER <br />TYPE OF INSPECTION <br />SITE COMPUTER # <br />PER # <br />PER # <br />PER # <br />PER # <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANKTANK <br />CONTENTS <br />"g," <br />.. .. .. .. <br />MAJOR MINOR <br />PERMIT TO OPERATE <br />1 2 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 4 <br />APPROVED CONSTRUCTION <br />5 6 <br />WRITTEN MONITORING PROCEDURES <br />7 8 <br />APPROVED MONITORING SYSTEM <br />9 10 <br />MONITORING SYSTEM <br />11 112 <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 REL ASE 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 />CONDITIONS ABATED <br />37 <br />g <br />TEMPORARY TANK CLOSURE <br />"F, <br />REMOVAL OF RESIDUAL 38 39 <br />FLAMMABLE VAPORS REMOVED 40 <br />ACCESS LOCATIONS SEALED 41 42 <br />POWER DISCONNECTED m 43 <br />OWNER/OPERATOR MONITORING 44 45 <br />i5l" <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS 46 47 <br />PIPING 48 49 <br />FLAMMABLE VAPORS REMOVED 50 <br />UNAUTHORIZED RELEASE 51 T;52 <br />SAMPLING 53 <br />54 <br />IMPROPER ABANDONMENT =55 56 <br />TFfE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) FOLLOWS: <br />57 58 59 <br />MAJOR E] MINOR Mi <br />VIOL. VIOL. LJ VIOL. <br />OFFICE: INSP. CEIVED E\T/' <br />TITLE: PhONE: <br />HUT -3 White - Original Yellow - Owner's Copy Pink - File Copv 5/88 (D M <br />