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OPERATIONAL TANK <br />U RGROUND TANK OFFICIAL INSPE N R RT <br />MAJOR MINOR <br />PERMIT TO OPERATE <br />_ <br />2 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 <br />SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPROVED CONSTRUCTION <br />COUNTY NAME <br />6 <br />445 N. San Joaquin Street <br />Mailing Address: P.O. Box 388 <br />Stockton, CA 95201.0388 <br />COUNTY # <br />8 <br />APPROVED MONITORING SYSTEM <br />488-3420 <br />10 <br />SITE NAME: <br />11 <br />12 <br />INSPECTION DATE: f— <br />SITE ADDRESS:4 <br />14 <br />TY/STATE/ZI <br />15 <br />16 <br />ACCESS TASING SECURED <br />17 <br />CHANGES SITE /O NEn/ PRMIT? YES <br />NO <br />TANK <br />TANK <br />TANK 3 <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />TANK GAUGING <br />COMPUTER <br />NUMBER <br />OMPUTER <br />NUMBE <br />COMPUTER <br />NUMBE <br />' <br />MPUTER <br />UMBER <br />TYPE OF INSPECTION <br />SITE COMPUTER # <br />27 <br />28 <br />SAMPLING <br />PER # <br />EXP. DAT <br />PER # <br />EXP. DAT <br />PER # <br />EXP. DAT <br />PER # <br />E.P. DATE <br />OPERATIONAL TANK <br />TANK CONTENTS <br />MAJOR MINOR <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 />10 <br />MONITO%NG SYSTEM <br />11 <br />12 <br />APPROVED MONITOR FREQUENCY <br />13 <br />14 <br />MONIT NG RECORDS MAINTAINED <br />15 <br />16 <br />ACCESS TASING 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 />SAFETY HAZARD <br />35 <br />36 <br />CONDITIONS ABATED <br />37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />38 39 <br />FLAMMABLE VAPORS REMOVED <br />40 <br />ACCESS LOCATIONS SEALED <br />41 <br />42 <br />POWER DISCONNECTED <br />43 <br />OWNER/OPERATOR MONITORING <br />44 <br />45 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />46 47 <br />PIPING A <br />48 <br />49 <br />FLAMMABLE VAPORS REMOVED <br />50 <br />UNAUTHORIZE114 RELEASE <br />51 <br />52 <br />SAMPLING <br />53 <br />54 <br />IMPROPER ABANDONMENT <br />55 <br />156 <br />iYSTEM STATUS (MUST MARK ONE) <br />57 58 <br />59 <br />MAJOR MINOR NO <br />❑ ❑ <br />VIOL. VIOL. VIOL. <br />OFFICE: INSP: <br />v <br />IT W <br />I_E: <br />HUT -3 White - Original Yellow - Owner's Copy Pink - File Copv <br />THE MARKED ITEMS <br />91 <br />VIOLATIONS AND MUST BE CORRECTED AS <br />!W�mm <br />5/88 O' M <br />