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J ,A <br />ARGROUND TANK OFFICIAL INSPECTION RORT <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 6 Stockton, CA 42®01-0388 COUNTY # 39 <br />SITE NAME: INSPECTION DATE: <br />SITE ADDRESS: / ® - CITY/STATE/ZIP <br />CHANGES SITE YES NO <br />FORM A AND/OR B SUBMITTED? <br />TANK <br />COMPUTER <br />NUMBER <br />TANK <br />COMPUTER <br />NUMBER <br />TANK p`7 <br />COMPUTER <br />NUMBER <br />TANK <br />COMPUTER <br />NUMBER <br />TYPE INS CTION <br />SITE COMPUTER # <br />PER # <br />PER # <br />PER # <br />PER # <br />` <br />EXP. DATE <br />EXP. DATE <br />EXP_ DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />PERMIT TO OPERATE <br />TANK coareHrs <br />, <br />. <br />IMPROPER ABANDONMENT <br />x" <br />MAJOR MINOR <br />1 2 <br />CHANGE IN CONDITIONS TO OPERATE <br />THE MARKED ITEMS <br />FOLLOWS' <br />REPRESENT VIOLATIONS <br />3 4 <br />APPROVED CONSTRUCTION <br />NO 5 <br />VIOL. <br />5 6 <br />WRITTEN MONITORING PROCEDURES <br />7 8 <br />APPROVED MONITORING SYSTEM <br />9 110 <br />OFFICE: <br />MONITORING SYSTEM <br />11 12 <br />V <br />V <br />V <br />APPROVED MONITOR FREQUENCY <br />TITLE: Q �-y <br />P N : <br />BECK: <br />13 14 <br />MONITORING RECORDS MAINTAINED <br />15 16 <br />ACCESS CASING SECURED <br />17 18 <br />PIPING <br />:. <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 30 <br />APPROVED TANK REPAIRS <br />31 32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 34 <br />SAFETY HAZARD 135 <br />136 <br />CONDITIONS ABATED <br />/ 37 <br />TEMPORARY TANK CLOSURE <br />Momw <br />s ; <br />PIPING <br />48 49 <br />REMOVAL OF RESIDUAL 38 39 <br />FLAMMABLE VAPORS REMOVED 40 <br />FLAMMABLE VAPORS REMOVED <br />50 <br />ACCESS LOCATIONS SEALED 41 42 <br />POWER DISCONNECTED 43 <br />_.. <br />51 52 <br />OWNER/OPERATOR MONITORING 44 45 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS 46 47 <br />Momw <br />s ; <br />PIPING <br />48 49 <br />FLAMMABLE VAPORS REMOVED <br />50 <br />_. <br />UNAUTHORIZED RELEASE <br />51 52 <br />SAMPLING <br />53 54 <br />IMPROPER ABANDONMENT <br />55 56 <br />THE MARKED ITEMS <br />FOLLOWS' <br />REPRESENT VIOLATIONS <br />AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />MAJOR 57 MINOR 58 <br />VIOL. E:] VIOL. ❑ <br />NO 5 <br />VIOL. <br />OFFICE: <br />INSP: <br />RECEIVED BY: <br />V <br />V <br />V <br />TITLE: Q �-y <br />P N : <br />BECK: <br />[AUT -3 WNte - Original Yellow - Owner's Coov Pink - Fite Coov <br />: - - <br />