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U%WAGROUND TANK OFFICIAL INSPECTION RE6T <br />SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N. San Joaquin Street <br />Mailing Address: P.O. Boz 388 <br />COUNTY NAME Stockton, CA 952014388 CONNiY # ? �1 <br />HUT -3 White - Original Yellow - Owner's Copy Pink - File Copy 5iee 0- <br />SITE NAME:G <br />(,02 0 rL S?b /C <br />PECTION DATE: <br />Z - -9 <br />SITE ADDRESS: <br />�DtJ <br />ITY/STATE/ZIP <br />Ca <br />CHANGES SITE/OWNER/PERMIT? <br />YES <br />NO <br />TANK <br />TANK <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />TYPE INSPECTION <br />COMPUTER <br />NUMBEFQ�b <br />COMPUTE <br />NUMBER Od0 <br />COMPUTER <br />NUMBER <br />COMPUTER <br />NUMBER <br />SITE COMPUTER <br />J`..(f_ <br /># <br />PER # <br />PER # <br />PER # <br />PER # <br />, NV <br />�� <br />EXP. DA LeFa <br />,/` /eS <br />EXP. DAT£ <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />TANK <br />CONWIM <br />MAJOR MINOR <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 />WRITTEN 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 />20 <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 />30 <br />APPROVED TANK REPAIRS <br />31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 <br />34 <br />SAFETY HAZARD <br />35 <br />36 <br />CONDITIONS ABATED <br />37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />W4445 <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />_ <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />47 <br />PIPING <br />49 <br />FLAMMABLE VAPORS REMOVED <br />!46 <br />UNAUTHORIZED RELEASE <br />52 <br />SAMPLING <br />54 <br />IMPROPER ABANDONMENT <br />55 <br />56 <br />THE MARKED ITEMS REPRES NT VIOLATIONS <br />AND MUST BE CORRECTED A13 <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS: I <br />57 58 <br />59 <br />MAJOR MINOR NO <br />❑ ❑ <br />VIOL. VIOL. VIOL. <br />OFFICE: INS <br />RECEIVED BY: <br />PHONE: <br />/ RECK: <br />1r TITLE: S /Z 643 <br />HUT -3 White - Original Yellow - Owner's Copy Pink - File Copy 5iee 0- <br />