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U GROUND TANK OFFICIAL INSPECTION R16RT <br />SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N. San Joaquin Street <br />COUNTY NAME Mailing Address: P.O. Box 388 <br />Stockton, CA 95201-0388 <br />468.3420 <br />' <br />[SITE <br />NAME: <br />COUNTY # <br />INSPECTION DATE: 77 <br />SITE ADDRESS: "! 6 CITY/STATE/ZIP k <br />® c <br />CHANGES SITE/OWNER/PERMIT? YES NO <br />FORM A AND/OR B SUBMITTED? <br />TANK I <br />COMPUTER <br />TANK <br />COMPUTER <br />TANK 3 <br />COMPUTER <br />TANK <br />COMPUTER <br />40 <br />NUMBER <br />PER # <br />NUMBER <br />PER # <br />NUMBER <br />PER # <br />NUMBER <br />PER # <br />TYPE OF INSPECTION <br />SITE COMPUTER # <br />43 <br />OWNER/OPERATOR MONITORING <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />TANK CONTENTS <br />MAJOR MINOR <br />4` « <br />R S: <br />PERMIT TO OPERATE <br />1 2 <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 10 <br />MONITORING SYSTEM <br />11 12 <br />APPROVED MONITOR FREQUENCY <br />13 14 <br />MONITORING RECORDS MAINTAINED <br />15 16 <br />---- .e_.. ..... _..-_ _ <br />.-. - <br />ACCESS CASING SECURED <br />17 18 <br />PIPING <br />INVENTORY RECONCILIATION <br />19 20 <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 <br />35 36 <br />CONDITIONS ABATED <br />/ 37 <br />TEMPORARY TANK CLOSURE <br />46 47 <br />48 49 <br />REMOVAL OF RESIDUAL <br />38 39 <br />FLAMMABLE VAPORS REMOVED <br />40 <br />56 <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 />PIPING <br />FLAMMABLE VAPORS REMOVED <br />UNAUTHORIZED RELEASE <br />SAMPLING <br />IMPROPER ABANDONMENT <br />46 47 <br />48 49 <br />50 <br />51 52 <br />53 54 <br />55 <br />56 <br />(STEM STATUS (MUST MARK ONE) <br />MAJOR 57 MINOR 58 NO 59 <br />VIOL. VIOL. ❑ VIOL. ❑ <br />OFFICE: INSP: <br />TITLE: <br />HUT -3 White - Original Yellow - Owner's Copy Pink. File Copy <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />FOLLOWS: <br />I <br />RECK: <br />5/88 0 M <br />