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UNN,oAGROUND TANK OFFICIAL INSPECTION RAT <br />SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N. Sen Joaquin Street <br />Malting Address: P.O. Box 388 <br />COUNTY NAME Stockton, CA 95201-0388 COUNTI # <br />4aA.A420 <br />SITE NAME:/ / <br />!/ <br />* ev© <br />INSPECTION DATE: <br />i <br />3- S <br />SITE ADDRESS: SOL <br />O� <br />CITY/STATE/ZIP <br />�� <br />CHANGES SITE/OWNER/PERMIT? YES <br />NO <br />TANK <br />TANK z <br />TANK 3 <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />TYPE OF INSPECTION SITE COMPUTER # <br />NUMBER <br />NUMBER <br />NUMBER <br />NUMBER <br />Z.� oB <br />Z <br />PER # <br />PER # <br />PER # <br />PER # <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK TANKCorneNrs <br />MAJOR MINOR Q� r�4 <br />-7 <br />%Z� Pyr' 1G DCx%�fYS. <br />PERMIT TO OPERATE 1 <br />2 <br />CHANGE IN CONDITIONS TO OPERATE 3 <br />4 ✓ <br />✓ .�- <br />APPROVED CONSTRUCTION 5 <br />6 <br />WRITTEN MONITORING PROCEDURES 7 <br />8 <br />APPROVED MONITORING SYSTEM 9 <br />10 <br />MONITORING SYSTEM 11 <br />12 <br />APPROVED MONITOR FREQUENCY 13 <br />14 <br />MONITORING RECORDS MAINTAINED 15 <br />16 <br />ACCESS CASING SECURED 17 <br />18 <br />PIPING <br />INVENTORY RECONCILIATION 21 <br />22 .�.�"" <br />✓— <br />TANK GAUGING 23 <br />24 <br />APPROVED RESPONSE PLAN 25 <br />26 <br />UNAUTHORIZED RELEASE OCCURRENCE 27 <br />28 <br />SAMPLING 29 <br />30 <br />APPROVED TANK REPAIRS 31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED <br />SAFETY HAZARDCONDITIONS <br />M37 <br />ABATED <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />39 <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />W447 <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />PERMANENT TANK CLOSURE <br />77-77 <br />REMOVAL OF RESIDUAL MATERIALS 46 <br />47 <br />PIPING 48 <br />49 <br />FLAMMABLE VAPORS REMOVED 50 <br />UNAUTHORIZED RELEASE 51 <br />52 <br />SAMPUNG 53 <br />54 <br />IMPROPER ABANDONMENT 55 <br />56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK <br />FOLLOWS: <br />5O8NE) <br />MAJOR 57 MINOR 6- IVIA 59 <br />❑ ❑ <br />VIOL. VIOL. LJ OL. <br />OFFICE: <br />INSG P:_ <br />B <br />_ <br />7(T- <br />. <br />TITLE: <br />PHONE: <br />RECK: <br />HUT -3 White - Original Yellow - Owner's Copy Pink - File Copy 5188 0 v. <br />