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U&dRGROUND TANK OFFICIAL INSPECTION RB1►016RT <br /> SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N.San Joaquin Street <br /> Mailing Address: P.O.Box 388 q <br /> COUNTY NAME 1S 6L-" O u Stockton,CA 95201-0388 COUNTY # / <br /> 468-3420 // G <br /> SITE NAME: INSPECTION DATE: <br /> n�Tp ' /� <br /> SITE ADDRESS: CITY/STATE/ZIP 6�2C*-L-- I� C/7 9 <br /> CHANGES SITE/OWNER/PERMIT'? 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 /> PER# PER# PER# PER# <br /> EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK TMJK COI r IfrS y <br /> MAJOR MINOR <br /> PERMIT TO OPERATE 1 2 <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 6 <br /> WRITTEN MONITORING PROCEDURES 7 6 ✓ <br /> APPROVED MONITORING SYSTEM 9 10 ✓ <br /> MONITORING SYSTEM 11 12 <br /> APPROVED MONITOR FREQUENCY 13 14 <br /> MONITORING RECORDS MAINTAINED 15 16 <br /> ACCESS CASING SECURED 17 18 ✓ (�lM /i74r ��� <br /> PIPING 19 20 <br /> INVENTORY RECONCILIATION 21 22 <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 <br /> REMOVAL OF RESIDUAL 38e43 <br /> FLAMMABLE VAPORS REMOVED 40 <br /> ACCESS LOCATIONS SEALED 41 <br /> POWER DISCONNECTED OWNER/OPERATOR MONITORING 44 <br /> PERMANENT TANK CLOSURE - x " <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(MUST MARK ONE) FOLLOWS: �-� <br /> 57 58 59 <br /> 14- <br /> VIOMAJOR ❑ VIOLL..R ❑ VIOL.❑ <br /> OFFICE: INSP_c.—r, A2• RECN7 0 <br /> Y. <br /> A, <br /> TITLE:SXrUl 0 ite <br /> RECK: <br /> HUT-3 White-Original Yellow-Owner's Copy Pink-File Copy 5iee O M <br />