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r UORGROUND TANK OFFICIAL INSPECTION R*T <br />• SAN JOAOUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 E. Weber Ave., TNrd Floor <br />Mailing Address: P.O. Box 388 <br />COUNTY NAME Stockton, CA 95201-0388 COUNTY # <br />468-3420 <br />SITE NAME: S INSPECTION DATE: / <br />SITE ADDRESS: CITY/STATE/ZIP <br />CHANGES SITE YES NO <br />FORM A AND/OR B SUBMITTED? <br />TANK <br />COMPUTER <br />NUMBER <br />PER # <br />EXP. DATE <br />TANK <br />COMPUTER <br />NUMBER <br />PER # <br />EXP. DATE <br />TANW <br />COMPUTER <br />NUMBER <br />PER # <br />EXP. DATE <br />TANK <br />COMPUTER <br />NUMBER <br />PER # <br />EXP. DATE <br />TYPE OF INSPECTION <br />SITE COMPUTER <br />OPERATIONAL TANK <br />PERMIT TO OPERATE <br />CHANGE IN CONDITIONS TO OPERATE <br />APPROVED CONSTRUCTION <br />WRITTEN MONITORING PROCEDURES <br />APPROVED MONITORING SYS IEM <br />MONITORING SYSTEM <br />APPROVED MONITOR FREQUENCY <br />MONITORING RECORDS MAINTAINED <br />ACCESS CASING SECURED <br />PIPING <br />TANK CONTENTS <br />MAJOR <br />MINOR <br />er ti.• <br />y {K S <br />I <br />31 <br />.. <br />1 <br />2 <br />135 <br />136 <br />42 <br />_ <br />3 <br />5 <br />4 <br />6 <br />7 <br />8 <br />9 <br />10 <br />11 <br />12 <br />13 <br />15 <br />14 <br />16 <br />17 <br />18 <br />19 <br />20 <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 />21 <br />22 <br />23 <br />24 <br />25 <br />26 <br />27 <br />28 <br />29 <br />30 <br />31 <br />32 <br />33 <br />34 <br />135 <br />136 <br />CONDITIONS ABATED <br />V37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />38 <br />139 <br />FLAMMABLE VAPORS REMOVED <br />40 <br />ACCESS LOCATIONS SEALED <br />41 <br />42 <br />POWER DISCONNECTED <br />= <br />43 <br />OWNER/OPERATOR MONITORING <br />44 <br />45 <br />PERMANENT TANK CLOSURE>l1�! <br />REMOVAL OF RESIDUAL MATERIALS <br />46 <br />47 <br />PIPING <br />48 <br />49 <br />FLAMMABLE VAPORS REMOVED <br />50 <br />UNAUTHORIZED RELEASE <br />51 <br />52 <br />SAMPLING <br />53 <br />54 <br />IMPROPER ABANDONMENT <br />55 <br />56 <br />THE MARKED ITEMS REPRESENT <br />—VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) FOLLOWS: �� � �2— ---- --- <br />57 58 59 <br />NO <br />VIOL. MAJOR ❑ VIOLL..R ❑ VOL. ❑ <br />OFFICE:-- <br />TIT <br />PHONE: <br />PECK: <br />HUT -3 While -Original Yellow - Owner's Copy Pink • File Copv <br />PHS 178 (4/96) , <br />