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OPERATIONAL TANK <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 />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />PIPING <br />FLAMMABLE VAPORS REMOVED <br />UNAUTHORIZED RELEASE <br />SAMPLING <br />IMPROPER ABANDONMENT <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 />38 39_ <br />U RGROUND TANK OFFICIAL INSPECTION ART <br />SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />COUNTY NAMEQ <br />445 N. San Joaquin Street <br />Mailing Address: P.O. Box 388 <br />Stockton. CA 95201-0388 <br />468-3420 <br />_ <br />COUNTY # <br />SITE NAME: <br />INSPECTION DATE: <br />SITE ADDRESS:CITY/STATE/ZIP <br />5 <br />Rd. <br />S�-,o Cff 4i� <br />43 <br />CHANGES SITE/OWNER/PERMIT? YES NO <br />TANK <br />TANK a <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />NUMBER <br />PER # <br />NUMBER <br />PER # <br />NUMBER <br />PER # <br />NUMBER <br />PER # <br />TYPE OF INSPECTION <br />SITE COMPUTER # <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK <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 />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />PIPING <br />FLAMMABLE VAPORS REMOVED <br />UNAUTHORIZED RELEASE <br />SAMPLING <br />IMPROPER ABANDONMENT <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 />38 39_ <br />40 <br />41 42 <br />43 <br />44 45 <br />I THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />57 58 59 <br />MAJOR MNO <br />VIOL. ❑ VIOLOR ❑ VIOL. ❑ <br />OFFICE: INSP: ® i <br />RECEI <br />TITLE. PHONE: <br />HUT -3 White - Original Yellow - Owner's Copy Pink - File Copy <br />1 <br />5/88 0M <br />