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UI%w6RGROUND TANK OFFICIAL INSPECTION RetbRT <br />SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N. Sen Joaquin Street <br />� Mailing Address: P.O. Box 388 <br />(b <br />COUNTY NAME Stockton, CA 85201-0388 <br />AA 1 ,moi iln n i... __ rmnlrr � -�n <br />HUT -3 White - Original Yellow -Owner's Copy Pink - File Copy ;, 6e G.M <br />403.3420 <br />U <br />SITE NAME: �' <br />Vo r <br />INSPECTION DATE:a <br />SITE ADDRESS: a D Iq <br />` <br />CITY/STATE/ZIP <br />SfpG�j <br />Ciep�() J <br />CHANGES SITE/OWNER/PERMIT? <br />YES <br />NO <br />TANK TANK <br />TANK <br />TANK <br />FORM AAND/ORB SUBMITTED? <br />COMPUTER COMPUTER <br />OMPUTER <br />COMPUTER <br />TYPE OF INSPECTION SRE COMPUTER # <br />NUMBER NUMBER <br />UMBER <br />NUMBER <br />rD a �-� n-C� a 3 a � 7 <br />PER # PER # <br />P R # <br />PER # <br />a <br />EXP. DATE EXP. DATE <br />E .DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />TA/tl CON1ENTS <br />r ! C r <br />/ <br />MAJOR MINOR <br />�1 <br />PERMIT TO OPERATE <br />1 <br />2 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 <br />4 <br />APPROVED CONSTRUCTION <br />5 <br />6 <br />WRfTTEN MONITORING PROCEDURES <br />7 <br />8 <br />APPROVED MONITORING SYSTEM <br />9 <br />10 <br />MONITORING SYSTEM <br />11 <br />12 <br />APPROVED MONITOR FREQUENCY <br />13 <br />14 <br />MONITORING RECORDS MAINTAINED <br />15 <br />16 <br />ACCESS CASING SECURED <br />17 <br />18 <br />PIPING <br />19 <br />p <br />INVENTORY RECONCILIATION <br />21 <br />22 <br />TANK GAUGING <br />23 <br />24 <br />APPROVED RESPONSE PLAN <br />25 <br />26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 <br />28 <br />SAMPLING <br />29 <br />APPROVED TANK REPAIRS <br />31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 <br />34 <br />SAFETY HAZARD <br />CONDITIONS ABATED <br />37 <br />� <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />W4445 <br />POWER DISCONNECTED <br />A_ <br />OWNER/OPERATOR MONITORING <br />PERMANENT TANK CLOSURE <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 VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />ZU,MAJ02� <br />FOLLOWS: <br />57 58 <br />OR ❑ ❑ <br />59 <br />❑ <br />U <br />VIOL VIOLO.R <br />VOL. <br />OFFICE: <br />INSP <br />RECEIVED BY: <br />`�'� <br />TITLE:5C-#16R RAE <br />HS <br />PHONE: <br />RECK: <br />HUT -3 White - Original Yellow -Owner's Copy Pink - File Copy ;, 6e G.M <br />