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^~� AGROUND TANK OFFICIAL INSPECTION *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 NAME Stockton, CA 95201-0388 <br />j 468-3420 <br />Fs -,TENAME: <br />MOW TANK <br />COMPUTER <br />TYPE OF INWECTION SITE COMPUTER # PER # <br />EXP. DATE <br />TANK CONTENTS !V <br />OPERATIONAL TANK <br />PERMIT TO OPERATE <br />CITY/STATE/ZIP <br />INSPECTION DATE: <br />TANK <br />TANK <br />TANK <br />coMPoTsn <br />oOwPoTsn <br />cowPoTsn <br />muwBEn <br />wumBEn <br />muwos9 <br />pEn# <br />|PsR# <br />PER # <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />CHANGE INCONDITIONS TDOPERATE <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 />n <br />INVENTORY RECONCILIATION <br />- <br />---- <br />---|-----------| <br />' <br />-- ' <br />- — <br />------___-_ <br />TANK GAUGING <br />9 10- <br />11 12- <br />13 14 <br />15 16------ <br />17 18--- <br />19 <br />, <br />TITLE -S,, 46�16 <br />HUT -3 White - Original Yellow - Owner's Copy Pink - File Coov <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 />HE <br />Tg <br />ME <br />REMOVAL OF RESIDUAL <br />38 39 <br />FLAMMABLE VAPORS REMOVED <br />40 <br />ACCESS LOCATIONS SEALED <br />41 424 <br />POWER DISCONNECTED <br />43 <br />OWNER/OPERATOR MONITORING <br />44 45 <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 />153 154 <br />IMPROPER ABANDONMENT <br />155 156 <br />THE MARKED ITEMS REPRESENT VIOLATION AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS:_ . A -Lka <br />57 58 <br />59 <br />VIOL. VIOL. VIOL. <br />I VI <br />, <br />TITLE -S,, 46�16 <br />HUT -3 White - Original Yellow - Owner's Copy Pink - File Coov <br />