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UJWGROUND TANK OFFICIAL INSPECTION ROT <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 />4AA _'i42n <br />SITE NAME:QP J osv Cu V-\ <br />`L� <br />INSPECTION DATE: /l 2 ! <br />SITE ADDRESS: (s() <br />Lk_) <br />lCLt� <br />CITY/STATE/ZIP <br />CHANGES SITE/OWNER/PERMIT? YES <br />NO <br />TANK S <br />TANK e <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />NUMBER <br />LA �^ <br />NUMBER'} <br />❑ <br />PER # L <br />NUMBER <br />PER* U 0'r - <br />NUMBER <br />PER # <br />TYPE OF INSPECTION <br />SITE COMPUTER +� <br />PER N <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />TANK CONTENTS <br />j' -v = v'' t 1 j, Y% } <br />! ��-y <br />J1 VLJ <br />MAJOR <br />MINOR <br />-J. <br />..,. <br />PERMIT TO 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 />IU <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 />/ <br />s <br />PIPING <br />19 <br />20 <br />Ob6o <br />t,�lCa Cy T1� <br />C,t.�5R�L1 (p <br />o� <br />!NVENTORY RECONCILIATION <br />4 <br />21 <br />22 <br />C- 1,W 7 <br />-X-.: u Y LCi t <br />\\ <br />CGS Vu,- <br />OLc5 <br />TANK GAUGING <br />23 <br />24 <br />APPROVED RESPONSE PLAN <br />25 <br />26 <br />W Cc <br />1Z /2 lQ (p <br />UNAUTHORIZED RELEASE OCCURRENCE 27 <br />28 <br />SAMPLING <br />29 <br />30 <br />APPROVED TANK REPAIFJS <br />31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED 33 <br />34 <br />SAFETY HAZARD • <br />35 <br />36 <br />CONDITIONS ABATED <br />37 <br />TEMPORARY TANK CLOSURE <br />WWI <br />',=� <br />REMOVAL OF RESIDUAL <br />38 <br />39 <br />FLAMMABLE VAPORS REMOVED <br />40 <br />ACCESS LOCATIONS SEALED <br />41 <br />42 <br />POWER DISCONNECTED <br />ME <br />43 <br />OWNER/OPERATOR MONITORING <br />44 <br />45 <br />PERMANENT TANK CLOSURE <br />`4 <br />REMOVAL OF RESIDUAL;MATERIALS <br />PIPING <br />49 <br />FLAMMABLE VAPORS REMOVED <br />k4647 <br />UNAUTHORIZED RELEASE <br />52 <br />SAMPLING <br />54 <br />IMPROPER ABANDONMENT <br />155 <br />56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS <br />AND MUST BE CORRECTED <br />AS <br />SYSTEM STATUS (MUSr MARK ONE) <br />FOLLOWS:57 <br />— <br />--- ---- <br />58 <br />59 <br />— <br />-- ... --- - --- <br />❑ ❑ <br />❑ <br />VIOL. VIOL. <br />VOL. <br />-- <br />— <br />OFFICE: <br />INSP: <br />RECEIVED BY: <br />C.S 1410K* <br />�!L, <br />PH <br />HECK: <br />TITLE: QctgS <br />1- IUT-3 White - Original Yellow - Owner's Copy Pink - File Copv <br />PHS 178 (4/96) <br />