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UrDERGROUND TANK OFFICIAL INSPECTION RePORT <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 COUNTY OUNTI # <br />SITE NAME: va= <br />INSPECTION DATE: <br />SITE ADDRESS: �p� fc <br />IE�oK�� <br />CITY/STATE/ZIP <br />CHANGES SITE/OWNER/PERMIT? <br />YES NO <br />TANK o' <br />TANK <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />TYPE OF INSPECTION SITE COMPUTER # <br />NUMBER <br />NUMBER <br />NUMBER <br />NUMBER <br />�' <br />PER # <br />PER # <br />PER # <br />PER # <br />•�� <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />TANK 00N NFS <br />WMR MINOR <br />PERMIT TO OPERATE <br />2 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 4 <br />APPROVED CONSTRUCTION <br />5 6 <br />WRITTEN MONITORING PROCEDURES <br />7 8 <br />APPROVED MONITORING SYSTEM <br />9 10 <br />MONITORING SYSTEM <br />11 12 <br />APPROVED MONITOR FREQUENCY <br />13 14 <br />MONITORING RECORDS MAINTAINED <br />15 16 <br />ACCESS CASING SECURED <br />17 18 <br />PIPING <br />19 20 - - <br />INVENTORY RECONCIUATION <br />21 22 <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 />REMOVAL OF RESIDUAL <br />9 <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />W44475 <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <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 />53 54 <br />IMPROPER ABANDONMENT <br />55 56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS:MAJ <br />57 58 <br />R ❑ MINOVIOL.R ❑ <br />59 <br />❑ <br />--- <br />VIOL VOL. <br />OFFICE: <br />INSP:G <br />RECEIVED BY: <br />TITLE: 'e. �=, /S_ <br />PHONE: 1� <br />RECK: <br />HUT -3 White- Original Yellow - Owner's Copy Pink - File Copy 5m 0 M <br />