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*RGROUND TANK OFFICIAL INSPECTION 1WRT <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 COUNTY # <br />SITE NAME: INSPECTION DATE: <br />5;/ , 5�v <br />SITE ADDRESS: 7S y CITY/STATE/ZIP <br />CHANGES SITE/OWN R/PERMIT? YES NO <br />TANK C71 <br />TANK OZ- <br />TANK o;3— <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER/off <br />COMPUTER/®k <br />COMPUTER <br />COMPUTER <br />91 <br />NUMBER &ye <br />PER # <br />EXP. DATE <br />NUMBER <br />PER # <br />EXP. DATE <br />NUMBER orc�he- <br />PER # A711e� <br />EXP. DATE <br />NUMBER <br />PER # <br />EXP. DATE <br />TYPE OF INSPECTION <br />/<Elz) 1r-7 —/Ikhc—�7 <br />SITE COMPUTER # <br />OPERATIONAL TANK <br />TANK C NTENTS <br />56 <br />1k, 211,111,1211 <br />REMO <br />MAJOR MINOR <br />PERMIT TO OPERATE <br />CHANGE IN CONDITIONS TO OPERATE <br />2 <br />3 4 <br />APPROVED CONSTRUCTION <br />5 6 <br />WRITTEN MONITORING PROCEDURES <br />�f) 8 <br />9 10 <br />APPROVED MONITORING SYSTEM <br />MONITORING SYSTEM <br />11 12 <br />APPROVED MONITOR FREQUENCYf <br />4 <br />X" <br />MONITORING RECORDS MAINTAINED <br />ACCESS CASING SECURED <br />—)— <br />ISD 16 <br />T7 18 <br />--------- -- - <br />- - , I - I � I <br />I I <br />PIPING <br />19 20 <br />INVENTORY RECONCILIATION <br />21 22 <br />TANK GAUGING <br />23 24 <br />APPROVED RESPONSE PLAN <br />2 26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 28 <br />SAMPLING <br />29 30 <br />APPROVED TANK REPAIRS <br />. <br />31 32 <br />........ ...... <br />UNAUTHORIZED RELEASES REPORTED <br />33 34 <br />SAFETY HAZARD <br />35 36 <br />CONDITIONS ABATED <br />=37 <br />..... <br />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />38 39 <br />REMOVAL OF RESIDUAL MATERIALS <br />40 <br />PIPING <br />48 <br />49 <br />41 42 <br />50 <br />91 <br />UNAUTHORIZED RELEASE <br />43 <br />52 <br />SAMPLING <br />53 <br />44 45 <br />IMPROPER ABANDONMENT <br />55 <br />56 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />46 47 <br />PIPING <br />48 <br />49 <br />FLAMMABLE VAPORS REMOVED <br />50 <br />91 <br />UNAUTHORIZED RELEASE <br />51 <br />52 <br />SAMPLING <br />53 <br />54 <br />IMPROPER ABANDONMENT <br />55 <br />56 <br />SYSTEM STATUS (MUST MARK ONE) <br />MAJOR 57 MINOR 58 NO 59 <br />VIOL. U VIOL. El VIOL. H <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />Fn I n%A/Q- 5AFA45 0�>4'11`365' Z <br />OFFICE: INSP: RECEIVED BY: c>41 t-> 11 / Al <br />e-4 450000/6 <br />TITLE: x> PHON�� 2�L 3-1 <br />HUT -3 White - Original Yellow - Owner's Copy Pink - File Copy 5/88 0 m <br />