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AGROUND TANK OFFICIAL INSPECTION RE T <br /> SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 306 E.Weber Ave.,Third Floor <br /> Melling Address:P.O.Box 3as <br /> COUNTY NAME SJ Q Stockton,CAas2m-o388 <br /> 468-3420 COUNTY # 3 <br /> SITE NAME: i �, INSPECTION DATE: /a-ilk-9�v <br /> SITE ADDRESS: � ) n f r / TY/STATE/ZIP O��O.5 <br /> CHANGES SITE YES NO TANK TANK TANK TANK/ <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> TYPE OF INSPECTION SITE COMPUTER♦ NUMBER NUMBER NUMBER NUMBER <br /> �©g , ��� / / PER # PER 0 PER # PER # <br /> (0 EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK TANK CONIENM ji I. . Zyi I 1 k/}1 5f( <br /> PERMIT TO OPERATE I 2 <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 6 <br /> WRITTEN MONITORING PROCEDURES 7 8 <br /> APPROVED MON[TORING SYS I EM 9 10 <br /> MONITORING SYSTEM 11 12 / <br /> APPROVED MONITOR FREQUENCY 13 14 V/ <br /> MONITORING RECORDS MAINTAINED 15 I6 <br /> ACCESS CASING SECURED 17 18 <br /> PIPING 19 20 <br /> INVENTORY RECONCILIATION 21 22 <br /> ..._.__.-.V........_..__.-. _ . _.__... <br /> TANK GAUGING 23 24 <br /> APPROVED RESPONSE PLAN 25 26 „✓ <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 28 <br /> SAMPLING 29 30 <br /> APPROVED TANK REPAIRS _ 31 32 <br /> UNAUTHORIZED RELEASES REPORTED 33 34 <br /> SAFETY HAZARD 35 36 <br /> CONDITIONS ABATED 37 <br /> TEMPORARY TANK CLOSURE (:. ..` r "� Pxx <br /> I` <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 /> PERMANENT TANK CLOSURE 7' <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(MUfir MARK ONE) FOLLOWS: <br /> MAJOR <br /> 57❑ MINOR 58 N 59 <br /> OL ❑ VOL.❑ —.__--___.—_. ___._— <br /> )FFICE: INSP: RE <br /> TITLE:Sr6 �� r P y L� r/ J PECK: <br /> -v 0T-3 While-Original Yellow-Owner's Copy Pink-File Coov 7 / � / <br /> /'y(/�'l PHS 178 (4/96) <br />