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UIibWRGROUND TANK OFFICIAL INSPECTION RbmdRT <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�'gM &U i�iv.� Stockton, CA 95201-0388 COUNTY #, <br />SITE NAME: <br />/ / INSPECTION DATE:3-7—�SL <br />SITE ADDRESS: S <br />' CITYI/STATE/ZIP S f C/g 85446 <br />CHANGES SITE /OWN7E'RI//PERMIT? <br />YES NO <br />TANK U / <br />TANK <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />NUMBER <br />NUMBER <br />NUMBER <br />NUMBER <br />TYPE OF INSPECTPN <br />SITE COMPUTER # <br />G'05 rOu+l <br />��" <br />ER <br />E <br />EXP DATE <br />XP DATE <br />EXP. DATE <br />EXP DATE <br />OPERATIONAL TANK <br />TANK CONTENTS , �6G�l_4 <br />MAJOR <br />MINOR �(�6) <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 n MA� <br />am,�Vict <br />APPROVED MONITOR FREQUENCY <br />13 <br />_L <br />14 1 <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 />_ <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 />_ <br />36 <br />CONDITIONS ABATED <br />37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />W4445t <br />POWER DISCONNECTED <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 />FOLLOWS:4'R/ <br />a1 <br />57 58 <br />59 <br />R ❑ <br />❑ <br />❑ <br />VIOL VIOL' VOL <br />OFFICE: <br />INSP: <br />j /1 _ .'„ i / <br />RECEIVED BY: <br />TITLE: <br />HONE: BECK: <br />HUT -3 White -Original Yellow -Owners Copy Pink - File Copy Sian "" <br />