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U^GROUND TANK OFFICIAL INSPECTION ROT <br />SAN JOAOUIN 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 />4N-3420 <br />SITE NAME: Z­4k�tvot>z 5*45u <br />MAJOR MINOR <br />INSPECTION DATE: <br />SITE ADDRESS: z <br />LANP-= <br />CITY/STATE/ZIP <br />CHANGES SITE/OWNER/PERMIT? <br />YES NO <br />TANK 1Z <br />TANK <br />TANK 1,7 L- TANK <br />FORM A AND/OR B SUBMITTED? <br />5 <br />COMPUTERCOMPUTER <br />COMPUTER COMPUTER <br />WRITTEN MONITORING PROCEDURES <br />7 <br />NUMBER <br />NUMBER <br />NUMBER NUMBER <br />TYPE OF INSPECTION <br />PER # <br />PER # -//-- <br />PER # ,-rf4 PER # <br />A7 C;r- rE 17COMPUTER <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE _EXP. DATE <br />OPERATIONAL TANK <br />TANK CONVENTS <br />'I , �, <br />"IT <br />T. <br />14 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />PIPING <br />FLAMMABLE VAPORS REMOVED <br />UNAUTHORIZED RELEASE <br />SAMPLING <br />IMPROPER ABANDONMENT <br />SYSTEM STATUS (MUST MARK ONE) <br />f 40, <br />f <br />46 _47 <br />48 49 <br />50 m <br />51 52 <br />53 54 <br />55 56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />FOLLOWS: <br />57 58 59 <br />MAJOR IVIIIA-A, No w, <br />01 VIOL. VIOL. H VIOL. X-4. <br />OFFICE: INSP: eG <br />TITLE: <br />I UT -3 While -Original Yellow - Owner's Copy Pink - File Copv <br />PHS 178 (4/96) <br />MAJOR MINOR <br />PERMIT 10 OPERATE <br />1 <br />2 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 <br />4 <br />APPROVED CONSTRUCTION <br />5 <br />6 <br />WRITTEN MONITORING PROCEDURES <br />7 <br />8 <br />APPROVED MONITORING SYSTEM <br />9 <br />10 <br />MONITORING SYSTEM <br />11 <br />12 <br />APPROVED MONITOR FREQUENCY <br />13 <br />14 <br />MONITORING RECORDS MAINTAINED <br />15 <br />16 <br />ACCESS CASING SECURED <br />17 <br />18 <br />PIPING <br />19 <br />20 <br />INVENTORY RECONCILIATION <br />21 <br />22 <br />TANK GAUGING <br />23 <br />24 <br />APPROVED RESPONSE PLAN <br />25 <br />26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 <br />28 <br />SAMPLING <br />29 <br />30 <br />APPROVED TANK REPAIRS <br />31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 <br />34 <br />_36 <br />SAFETY HAZARD <br />35- <br />CONDITIONS ABATED <br />En <br />37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />PIPING <br />FLAMMABLE VAPORS REMOVED <br />UNAUTHORIZED RELEASE <br />SAMPLING <br />IMPROPER ABANDONMENT <br />SYSTEM STATUS (MUST MARK ONE) <br />f 40, <br />f <br />46 _47 <br />48 49 <br />50 m <br />51 52 <br />53 54 <br />55 56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />FOLLOWS: <br />57 58 59 <br />MAJOR IVIIIA-A, No w, <br />01 VIOL. VIOL. H VIOL. X-4. <br />OFFICE: INSP: eG <br />TITLE: <br />I UT -3 While -Original Yellow - Owner's Copy Pink - File Copv <br />PHS 178 (4/96) <br />