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U6..0RGROUND TANK OFFICIAL INSPECTION R,,JRT <br /> SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N.San Joaquin Street <br /> Mailing Address: P.O.Box 388 <br /> COUNTY NAME StocktoCA 42001-0388 COUNTY # <br /> SITE NAME: <br /> n a Lv be INSPECTION DATE: <br /> SITE ADDRESS: CITY/STATE/ZIP <br /> 0 4narnei �� <br /> CHANGES SITE/OWNER/PERMIT? YE TANK 7 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 UNK CONWNTS C {{ <br /> MAJOR MINOR <br /> PERMIT TO OPERATE 1 2 <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 -6 <br /> — <br /> WRITTEN MONITORING PROCEDURES 7 - <br /> 8T-APPROVED MONITORING SYSTEM g 10 <br /> MONITORING SYSTEM 11 12 <br /> APPROVED MONITOR FREQUENCY 13 14 <br /> MONITORING RECORDS MAINTAINED 15 16 <br /> ACCESS CASING SECURED 17 16 <br /> PIPING 1g 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 2g 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 W43 <br /> FLAMMABLE VAPORS REMOVED <br /> ACCESS LOCATIONS SEALED <br /> POWER DISCONNECTED OWNER/OPERATOR MONITORING <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 57 MINOR ;58f/ NO 59 <br /> VIOL. ❑ VIOL. VIOL❑ <br /> OFFICE: INSd' / EIVED BY: � <br /> TITLE: P ONE: RECK: <br /> HUT-3 White-Original Yellow-Owner's Copy Pink-File Copy 5/BB �. <br />