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4 <br />C <br />COUNTY NAME_S;a,, <br />, I m/F� W/A <br />U&GROUND TANK OFFICIAL INSPECTION R <br />SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N. San Joaquin Street <br />Mailing Address: P.O. Box 388 <br />Stockton, CA 95201-0388 <br />46-8-3420 COUNTY# <br />INSPECTION DATE: <br />SITE ADDRESS: --I-- CITY/STATE/ZIP <br />CHANGES SITE/OWNER/PERMIT? YES NO <br />TANK <br />TANK <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />NUMBEP12�ffW <br />PER # <br />EXP. DATE <br />COMPUTER <br />NUMBER/rt j0ZM <br />PER # <br />EXP. DATE <br />COMPUTER <br />NUMBER <br />PER # <br />EXP. DATE <br />COMPUTER <br />NUMBER <br />PER # <br />EXP. DATE <br />TYPE OF INSPECTION —SITE <br />4&u4vv�4 <br />COMPUTER # <br />z , 1 <br />OPERATIONAL TANK <br />TANK CONTENTS <br />MAJOR MINOR <br />Sm lui'21 " <br />,00 <br />-4 ....... . . .. — <br />msimm% <br />mo!, <br />1 2 <br />PERMIT TO OPERATE <br />CHANGE IN CONDITIONS TO OPERATE <br />3 4 <br />APPROVED CONSTRUCTION <br />MONITORING PROCEDURES <br />5 6 <br />-1—/WRITTEN <br />7 8 <br />APPROVED MONITORING SYSTEM <br />MONITORING SYSTEM <br />9 610 <br />11 / 12 <br />APPROVED MONITOR FREQUENCY <br />13 14 <br />MONITORING RECORDS MAINTAINED <br />15 16 <br />ACCESS CASING SECURED <br />PIPING <br />17 18 <br />19 vo"'20 <br />INVENTORY RECONCILIATION <br />---------- - <br />21 22 <br />TANK GAUGING <br />APPROVED RESPONSE PLAN <br />23 011 24 <br />2-5 Vor 26 <br />.. ......... ... <br />........... <br />............. <br />. /---- ----- - <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 />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />=fti Ji F—il 0 121 il I a f-il L, 1 011-1111.11 a <br />REMOVAL OF RESIDUAL MATERIALS <br />PIPING <br />FLAMMABLE VAPORS REMOVED <br />UNAUTHORIZED RELEASE <br />SAMPLING <br />IMPROPER ABANDONMENT <br />38 39 <br />40 <br />41 42 <br />M!473- <br />44 45 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />;YSTEM STATUS 7(mus MARK ONE) <br />57 58 59 <br />MAJOR MINOR NO <br />VIOL. VIOL. El VIOL. F] <br />OFFIC INSP- <br />TITLE: —_ RHONE: <br />HUT -3 White - Original Yellow - Owner's Copy Pink - File Copv <br />mm <br />RECK: <br />5/88 0 <br />