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AGROUND TANK OFFICIAL INSPECTION RART <br /> SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N.San Joaquin Street <br /> COUNTY NAME Mailing Address: A.O.Box 388 <br /> �-0 a Stockton,CA 85201-0388 <br /> 468-3420 COUNTY # <br /> SITE NAME: -jrr U C INSPECTION DATE: <br /> SITE ADDRESS: ? / 33 D ic� r �,�+ CITY/STATE/ZIR �� �. � ' � 75al <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK 1 jJ TANK TANK TANK <br /> FORM A AND/OR 8 SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> TYPE OF INSPECTION SITE COMPUTER# NUMBER NUMBER NUMBER NUMBER <br /> 1 a PER# PER # PER # # <br /> ro� rl I-Lo PER <br /> FXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK TANK eonnENTs c' /' jai+ 4 <br /> MAJORMINOR k S } 1 <br /> PERMIT TO OPERATE 1 2 = J <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 6 <br /> WRITTEN MONITORING PROCEDURES 7-7 8 <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 <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 OF 37 <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL 38 139 <br /> FLAMMABLE VAPORS REMOVED 40 <br /> ACCESS LOCATIONS SEALED 41 42 <br /> POWER DISCONNECTED 43 <br /> OWNER/OPERATOR MONITORING 44 45 <br /> PERMANENT TANK CLOSURE <br /> REMOVAL OF RESIDUAL MATERIALS P48 <br /> 6 47 <br /> PIPING 149 <br /> FLAMMABLE VAPORS REMOVED 5D <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 /> MINOR No <br /> VIOL R VIOL VIOL. <br /> OFFICE: INSP:,, t R EIV BY <br /> Al <br /> TITLE,S5j0I0R R NE: BECK: <br /> j <br /> HUT-3 White-Original Yellow-Owner's Copy Pink-File Copy 5/a6 O <br />