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UN`!ffRGROUND TANK OFFICIAL INSPECTION R@rORT <br /> SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N.San Joaquin Street <br /> COUNTY NAME �p - <br /> Mailing Ston,CL C 952 83x 388 COUNTY # j y <br /> Stockton,CA 95201-0388 8388 [y <br /> 420 <br /> SITE NAME: I INSPECTION DATE: <br /> r <br /> SITE ADDRESS: CITY/STATE/ZIP Fid �1 <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 /> roa+i 1'O &,LO PER# PER# PER# PER# <br /> Ti O w w EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK TAk CON1EN1s <br /> MAIOR 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 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 ABATEDF11-717 <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL 38 39 <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 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 /> MAJOR 57MINOR 58 NO 59 <br /> VIOL. VIOL. VIOL <br /> OFFICE: INSP: 4GIt/ RECEIVED BY: <br /> TITLE: -Rt n PHONE: RECK: <br /> HUT-3 WNte-Original Yellow-Ownees Copy Pink-File Copy siea OM 00, <br />