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UNIGROUND TANK OFFICIAL INSPECTION REOT <br />SAN JOAOUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 E. Weber Ave., rd Floor <br />Mailing Address: P.O. Box 388 <br />COUNTY NAME Stockton, CA 95201-0388 <br />.ea-u9n <br />SITE NAME: Ck <br />SITE ADDRESS: <br />CHANGES SITE/OWNER/PERMIT? YES NO <br />FORM A AND/OR B SUBMITTED? <br />TANK <br />COMPUTEF <br />NUMBER <br />TYPE OF INSPECTION <br />• <br />SITE COMPUTER # <br />PER # <br />EXP. DATE <br />OPERATIONAL TANK <br />PERMIT TO OPERATE <br />CHANGE IN CONDITIONS TO OPERATE <br />APPROVED CONSTRUCTION <br />WRITTEN MONITORING PROCEDURES <br />APPROVED MONITORING SYSTEM <br />MONITORING SYSTEM <br />APPROVED MONITOR FREQUENCY <br />MONITORING RECORDS MAINTAINED <br />ACCESS CASING SECURED <br />PIPING <br />,NVENTORY RECONCILIATION <br />TANK GAUGING <br />APPROVED RESPONSE PLAN <br />UNAUTHORIZED RELEASE OCCURRENCE <br />SAMPLING <br />APPROVED TANK REPAIRS <br />UNAUTHORIZED RELEASES REPORTED <br />SAFETY HAZARD # <br />CONDITIONS ABATED <br />-mmCONTENTS <br />MAJOR I ININOR <br />TANK t4 <br />1 2 <br />y\ V <br />l <br />... ............... <br />................... <br />3 4 <br />5 16 <br />7 8 <br />9 t0 <br />11 12 <br />13 14 <br />15 16 <br />17 18 <br />19 20 <br />21 22 <br />23 124 <br />25 26 <br />27 28 <br />29 30 <br />31 32 <br />33 34 <br />35 136 <br />/ 37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL* <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />PIPING <br />FLAMMABLE VAPORS REMOVED <br />UNAUTHORIZED RELEASE <br />SAMPLING <br />IMPROPER ABANDONMENT <br />SYSTEM STATUS (MUST MARK ONE) <br />36 139 <br />40 <br />41 42 <br />43 <br />44 45 <br />46 47 <br />48 49 <br />_5091 <br />51 52 <br />53 54 <br />55 56 <br />NO <br />I VIOL.. R 57 58 59 <br />❑ VIOLL..R ❑ VOL. F] <br />COUNTY # <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />FOLLOWS: — ---------- <br />OFFICE: INSP:RECEIVED BY: <br />"--j©Std(oKR <br />TITLE: PHON BECK: <br />HUT -3 White -Original Yellow - Owner's Copy Pink - File Copv <br />PHS 178 (4/96) <br />INSPECTION DATE: <br />CITY/STATE/ZIP <br />TANK '�, <br />TANK 3 <br />TANK t4 <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />NUMBER <br />NUMBER <br />NUMBER <br />PER # <br />PER # <br />PER # <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />t <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />FOLLOWS: — ---------- <br />OFFICE: INSP:RECEIVED BY: <br />"--j©Std(oKR <br />TITLE: PHON BECK: <br />HUT -3 White -Original Yellow - Owner's Copy Pink - File Copv <br />PHS 178 (4/96) <br />