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ARGROUND TANK OFFICIAL INSPECTION SORT <br />SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N. San Joaquin Street <br />COUNTY NAME <br />Mailing Address: P.O. Box 388 <br />Stockton, <br />CA 95201-0388 <br />COUNTY # <br />468-3420 <br />SITE NAME:vim----INSPECTION <br />DATE: <br />SITE ADDRESS: <br />At CITY/STATE/ZIP <br />CHANGES SITE/OWNER/PERMIT? <br />YES NO TANK TANK ®f TANK® <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER COMPUTER COMPUTE COMPUTER <br />TYPE OF INSPECTION SITE COMPUTER # NUMBER NUMBER NUMBER NUMBER <br />PER # PER # PER # PER # <br />_50 <br />EXP. DATE EXP. DATE EXP. DATE EXP. DATE <br />OPERATIONAL TANK <br />TANK CONTENTS <br />MAJOR MINOR <br />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 18 1 <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 />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 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 />"g <br />REMOVAL OF RESIDUAL <br />38 39 <br />442M7MM <br />FLAMMABLE VAPORS REMOVED <br />40 <br />ACCESS LOCATIONS SEALED <br />41 <br />POWER DISCONNECTED <br />m 43 1- ' <br />OWNER/OPERATOR MONITORING <br />[44 145 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />46 47 <br />PIPING <br />48 49 <br />FLAMMABLE VAPORS REMOVED <br />50 <br />UNAUTHORIZED RELEASE <br />51 52 <br />SAMPLING <br />53 54 <br />IMPROPER ABANDONMENT <br />55 56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS:_ <br />57 58 <br />MAJOR Ei . MINOREi NO <br />VIOL.❑ <br />59 <br />H <br />VIOL. VOL. <br />OFFICE: I N S P: RECEIVED BY: <br />TITLE: PHONE: BECK: <br />MUT®3 White-Odginal Yellow -Owner's Copy <br />Pink - File CoDv <br />