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COUNTII NAME <br />11.116,RGROUND TANK OFFICIAL INSPECTION BORT <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 />APR Aon COUNTY # <br />ITE NAME: LJ SCK Aj <br />INSPECTION DATE: <br />SITE ADDRESS:Q C) r � �0.c/� <br />CITY/STATE/ZIP <br />CHANGES SITE/OWNER/PERMIT? <br />YES <br />NO TANK <br />TANK <br />TANK TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTE <br />COMPUTERCOMPUTER <br />COMPUTER' <br />TYPE OF INSPECTION SITE COMP# <br />NUMBER NUMBER u� T <br />LUTER <br />NUMBER NUMBER <br />L''�(� <br />PER # <br />PER # <br />PER # PER # <br />_.-• <br />— <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE EXP. DATE <br />OPERATIONAL TANK <br />TANK CONTEN75 <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 />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 />AMPLING <br />29 <br />30 <br />PROVED 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 CLOSUREft <br />11 , <br />.,.: <br />REMOVAL OF RESIDUAL <br />38 <br />139 <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 />r <br />REMOVAL OF RESIDUAL MATERIALS <br />46 <br />47 <br />PIPING <br />48 <br />49 <br />FLAMMABLE VAPORS REMOVED <br />50 <br />UNAUTHORIZED RELEASE <br />51 <br />52 <br />SAMPLING <br />53 <br />54 <br />IMPROPER ABANDONMENT <br />155 <br />156 l� <br />r/ <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS: <br />57 58 <br />59 <br />------ <br />MAO <br />❑IL. V INO. R ❑ <br />❑ <br />VOL. <br />OFFICE: <br />INSP: <br />� <br />RECEIVED BY: <br />�� 80 AC $9 <br />TIT��l <br />ZjEH3 <br />PHONE: <br />BECK: <br />HUT -3 White - Original Yellow - Owner's Copy Pink - File Cow f— riFA i M <br />