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2 <br />USGROUND TANK OFFICIAL INSPECTION R*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 <br />468-3420 <br />SITE NAME: <br />SITE ADDRESS: 14-rn <br />CHANGES SITE /OWNER/PERMIT? YES NO TANK <br />11FORM A AND/OR B SUBMITTED? COMPUTER <br />TYPE OF INSPECTION SITE COMPUTER # NUMBER <br />PFR * <br />mlflil� , - <br />'NSPECTION DATE: <br />CITY/STATE/ZIP S <br />TANK <br />Z <br />TANK <br />TANK <br />COMPUTER <br />COMPUTER -3 <br />CCIMPU�TR <br />NUMBER <br />NUMBER <br />NUMBER <br />PER # <br />5 6 <br />PER # <br />PER # <br />EXP. DATE <br />WRITTEN MONITORING PROCEDURES <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />PERMIT TO OPERATE <br />T <br />TANK C NTENTS <br />MAJOR MINOR <br />1 2 <br />0, <br />IM <br />CHANGE IN CONDITIONS TO OPERATE <br />3 4 <br />APPROVED CONSTRUCTION <br />5 6 <br />WRITTEN MONITORING PROCEDURES <br />7 8 <br />APPROVED MONITORING SYSTEM <br />9 110 <br />MONITORING SYSTEM <br />11 12 <br />APPROVED MONITOR FREQUENCY <br />13 14 <br />MONITORING RECORDS MAINTAINED <br />15 16 <br />ACCESS CASING SECURED <br />17 18 <br />PIPING <br />19 20 <br />INVENTORY RECONCILIATION <br />21 22 <br />TANK GAUGING <br />23 24 <br />APPROVED RESPONSE PLAN <br />25 26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 28 <br />SAMPLING <br />29 TI; <br />APPROVED TANK REPAIRS <br />31 32 <br />- ----- <br />UNAUTHORIZED RELEASES REPORTED <br />33 34 <br />SAFETY HAZARD <br />35 36 <br />CONDITIONS ABATED <br />37 <br />TEMPORARY TANK CLOSURE <br />gng <br />g <br />m <br />g <br />ON <br />A, <br />REMOVAL OF RESIDUAL <br />3839 <br />FLAMMABLE VAPORS REMOVED <br />!4421M <br />40 <br />ACCESS LOCATIONS SEALED <br />41 <br />POWER DISCONNECTED <br />43 <br />OWNER/OPERATOR MONITORING <br />44 45 <br />PERMANENT TANK CLOSURE <br />Ma <br />REMOVAL OF RESIDUAL MATERIALS 46 47 <br />PIPING 48 49 <br />FLAMMABLE VAPORS REMOVED 50 <br />UNAUTHORIZED RELEASE 51 52_ <br />SAMPLING 153 154 <br />IMPROPER ABANDONMENT 55 56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) FOLLOV <br />IS: <br />MAJOR <br />57 MINOR Im 58 D 59V <br />VIOL. ❑ VIOL. ❑ VIOL. <br />OFFICE: INP <br />fZ/RECEIVED BY: <br />TITLE: PHONE: 1_X <br />H[IT-3 Wlite-Orlainal Yellow -Owner's Coov Pink - File Conv <br />