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%IiIERGROUND TANK OFFICIAL INSPECTION R%.oORT • SAN JOAQUIN PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 E.Weber Am. hi,d Floor Meiling Address:P.O.Boz 388 COUNTY NAME Stmklon•CA95201-OM COUNTY # 488-3420 SITE NAME: L INSPECTION DATE: 6 SITE ADDRESS: �a 7 _ CITY/STATE/ZIP p+ CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK TANK TANK FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER NUMBER NUMBER NUMBER NUMBER TYPE OF INSPECTION SITE COMPUTER A PER# PER OF PER d PER R EXP.DATE EXP.DATE EXP.DATE EXP.DATE OPERATIONAL TANK TM*CO11E1'g +" r + s +i AIJOP MINOR AW- PERMIT TO OPERATE 1 2 CHANGE IN CONDITIONS TO OPERATE 3 4 APPROVED CONSTRUCTION 5 6 WRITTEN MONITORING PROCEDURES 7 8 APPROVED MONITORING SYSI EM 9 10 MONITORING SYSTEM 11 12 APPROVED MONITOR FREQUENCY 13 M MONITORING RECORDS MAINTAINED 15 16 ACCESS CASING SECURED 17 18 PIPING 19 20 INVENTORY RECONCILIATION 21 22 TANK GAUGING 23 24 APPROVED RESPONSE PLAN 25 26 UNAUTHORIZED RELEASE OCCURRENCE 27 28 SAMPLING 29 30 APPROVED TANK REPAIIIS 31 32 UNAUTHORIZED RELEASES REPORTED 33 34 _ SAFETY HAZARD a 35 36 CONDITIONS ABATED 37 _ e TEMPORARY TANK CLOSURE REMOVAL OF RESIDUAL" 38 39 FLAMMABLE VAPORS REMOVED 40 ACCESS LOCATIONS SEALED 41 42 POWER DISCONNECTED 43 OWNER/OPERATOR MONITORING 44 45 Ci ma" PERMANENT TANK CLOSURE 11 • w yT REMOVAL OF RESIDUAL.MATERIALS [55 47 PIPING 49 FLAMMABLE VAPORS REMOVED UNAUTHORIZED RELEASE 52 SAMPLING 54 IMPROPER ABANDONMENT 56 THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS SYSTEM STATUS(MUST MARK ONE) FOLLOWS: 5W-T3 �10190 SMA, 2 — 56 NO 59 p OR 57❑ MOOR ❑ VOL.❑ OFFICE: INSP: dl RECEIy D B Rl IY: ,"rAnlmlvg TITLE: F, 3'^c PHONE: HECK: HUT-3 White-Original Ye"Ow-owner's COPY Pink-File Copv PHS 178 (4/96)