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UN GROUND TANK OFFICIAL INSPECTION T <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 COUNTY # <br /> 468-3420 <br /> SITE NAME: INSPECTION DATE: / <br /> SITE ADDRESS: ® CITY/STATE/ZIP AtJ CA _ <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK TANK TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> TYPE OF INSPECTION SITE COMPUTER# NUMBER NUMBER NUMBER NUMBER <br /> 4 EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> ATIL TANK TANS coN�wTsw <br /> OR mammum :M-M_ <br /> PERMIT TO OPERATE 1 2 <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 6 <br /> WRITTEN MONITORING PROCEDURES 7 8 <br /> APPROVED MONITORING SYSTEM 9 10 <br /> MONITORING SYSTEM 11 12 <br /> APPROVED MONITOR FREQUENCY 13 14 <br /> MONITORING RECORDS MAINTAINED 15 16 <br /> ACCESS CASING SECURED 17 18 <br /> PIPING 19 20 <br /> INVENTORY RECONCILIATION 21 22 <br /> TANK GAUGING 23 24 ' <br /> APPROVED RESPONSE PLAN 25 26 <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 28 <br /> SAMPLING 29 30 - <br /> APPROVED TANK REPAIRS 31 32 <br /> UNAUTHORIZED RELEASES REPORTED 33 34 <br /> SAFETY HAZARD 35 36 <br /> _ � .. <br /> CONDITIONS ABATED 37— :3j ­­ <br /> TEMPORARYTANK CLOSURE ' <br /> REMOVAL OF RESIDUAL 38 !42 <br /> FLAMMABLE VAPORS REMOVED 40 <br /> ACCESS LOCATIONS SEALED 41 <br /> POWER DISCONNECTED 43 <br /> OWNER/OPERATOR MONITORING 44 45 <br /> PERMANENT TANK CLOSURE y n1 <br /> REMOVAL OF RESIDUAL MATERIALS 46 47 <br /> PIPING 48 49 <br /> FLAMMABLE VAPORS REMOVED V53 <br /> UNAUTHORIZED RELEASE 52 <br /> SAMPLING 54IMPROPER ABANDONMENT 56 <br /> THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONE) FOLLOWS:MAJOR NO <br /> ` <br /> 57 58 59 <br /> VIOL. ElVIOL..R ❑ VOL.❑ c. <br /> OFFICE: INSP: RECEIVED BY: <br /> TITLE: �. S, PHONE: BECK: <br /> HUT®3 WNW-Original Yellow-Owner's Cobv Pink-File Conv <br />