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t <br /> UIftieIRGROUND TANK OFFICIAL INSPECTION RST <br /> SAN JOAOUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.Weber Ave.,Third Floor <br /> Mailing Address:P.O.Box 388 <br /> COUNTY NAME Stockton,CA 95201-0388 COUNTY # <br /> 468-3420 <br /> SITE NAME: AW INSPECTION DATE: <br /> SITE ADDRESS: `��p 7 Al �,5! Lzz- <br /> TANK <br /> CITY/STATE/ZIP - , ,�� <br /> CHANGES SITE YES NO TANKrs�-( TANK TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> NUMBER NUMBER NUMBER NUMBER <br /> TYPE OF INSPECTION SITE COMPUTER <br /> PER# PER PER# PER# <br /> EXP.DATE EXP DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK TANK CONTENTS % <br /> -- - <br /> PERMIT TO OPERATE 1 2 <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 6 <br /> WRITTEN MONITORING PROCEDURES 7 8 <br /> APPROVED MONITORING SYSTEM 9 10 <br /> MONITORING SYSTEM 11 12 <br /> APPROVED MONITOR FREQUENCY 13 14 <br /> MONITORING RECORDS MAINTAINED 15 16 <br /> ACCESS CASING SECURED 17 18 <br /> PIPING [35 <br /> 20 <br /> ;NVENTORY RECONCILIATION 22 <br /> TANK GAUGING 24 <br /> APPROVED RESPONSE PLAN 26 <br /> UNAUTHORIZED RELEASE OCCURRENCE 28 <br /> SAMPLING <br /> APPROVED TANK REPAIRS 32 <br /> UNAUTHORIZED RELEASES REPORTED 34 <br /> SAFETY I IAZARD 36 <br /> CONDITIONS ABATED 37 <br /> TEMPORARY TANK CLOSURE t� z <br /> > <br /> 77� '- .- <br /> - T .-1 K� .iC !.i•-t <br /> REMOVAL OF RESIDUAL 38 39 <br /> FLAMMABLE VAPORS REMOVED 40 <br /> ACCESS LOCATIONS SEALED 41 42 <br /> POWER DISCONNECTED = 43 <br /> OWNER/OPERATOR MONITORING 44 45 <br /> MANENT TANK CLO <br /> ^lM, � i•Ite' r'!na 1 t c j K. ri te. <br /> REMOVAL OF RESIDUAL MATERIALS 46 47 <br /> PIPING 48 49 <br /> FLAMMABLE VAPORS REMOVED 50 <br /> UNAUTHORIZED RELEASE 51 52 <br /> SAMPLING 53 54 <br /> IMPROPER ABANDONMENT 55 56 <br /> THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONE) FOLLOWS:- <br /> 57 <br /> OLLOWS: ��-- -- --- <br /> VIO OR ❑ MI L.NOR No <br /> ❑ VOL.❑ _ ------ — -- <br /> OFFICE: INSP.. RECEIVED BY: <br /> TITLE: oe. 957 4/ PHONE: BECK: <br /> HUT-3 While-Original Yellow.Owner's Copy Pink-File Copy <br /> PHS 178 (4/96) <br />