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U GROUND TANK OFFICIAL INSPECTION R RT <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 NAEStockton, CA 95201-0388 COUNTY # <br />468-3420 <br />SITE NAME: <br />SITE ADDRESS: <br />`® <br />CHANGES SITE/OWNER/PERMIT? YES NO TANK <br />FORM A AND/OR B SUBMITTED? COMPUTER <br />TYPE OF INSPECTION SITE COMPUTER # NUMBER <br />1.PER # <br />OPERATIONAL TA <br />PERMIT TO OPERATE <br />CHANGE IN CONDITIONS TO OPERATE <br />APPROVED CONSTRUCTION <br />WRITTEN MONITORING PROCEDURES <br />APPROVED MONITORING SYSTEM <br />MONITORING SYSTEM <br />APPROVED MONITOR FREQUENCY <br />MONITORING RECORDS MAINTAINED <br />ACCESS CASING SECURED <br />PIPING <br />INVENTORY RECONCILIATION <br />TANK GAUGING <br />APPROVED RESPONSE PLAN <br />UNAUTHORIZED RELEASE OCCURRENCE <br />SAMPLING <br />APPROVED TANK REPAIRS <br />UNAUTHORIZED RELEASES REPORTED <br />SAFETY HAZARD <br />CONDITIONS ABATED <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />REMOVAL OF RESIDUAL MATERIALS <br />PIPING <br />FLAMMABLE VAPORS REMOVED <br />UNAUTHORIZED RELEASE <br />SAMPLING <br />IMPROPER ABANDONMENT <br />YSTEM STATUS (MUST MARK ONE) <br />MAJOR 57 MINOR 58 <br />VIOL. ElVIOL. ❑ <br />ME <br />TANK CONTENTS <br />MAJOR MINOR <br />1 2 <br />3 4 <br />5 6 <br />7 8 <br />9 10 <br />11 12 <br />13 14 <br />15 16 <br />17 18 <br />19 20 <br />21 22 <br />23 24 <br />25 26 <br />27 28 <br />29 30 <br />31 32 <br />33 34 <br />35 36 <br />//. 37 <br />�Im <br />=N <br />=m <br />V a <br />�m <br />59 <br />NO <br />VIOL. ❑ <br />INSPECTION DATE: <br />CITY/STATE/ZIP ® t <br />TANK <br />TANK <br />WANK <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />NUMBER <br />NUMBER <br />NUMBER <br />PER # <br />PER # <br />PER # <br />EXP. DgE <br />EXP. DATE i-JPW EXP. DATE <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />OFFICE: INSP- <br />Tr, , H. S <br />TITLE <br />H( IT -3 WNte - Or'seinal Yellow - Owner's Cnnv Pink - Fua rnn„ <br />W!I«` <br />RECEIVED . <br />. q <br />