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UN'GROUND TANK OFFICIAL INSPECTION REIRT <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 NAME0.� 3 Stockton,CA 95201-0388 <br /> 468-3420 COUNTY # r3 G/ <br /> SITE NAME: T INSPECTION DATE: <br /> SITE ADDRESS: 1 CITY/STATE/ZIP <br /> CHANGES SITE/OWNER/PERMIT? NO TANK TANK 2 TANK TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTE13 COMPUTER COMPUTER COMPUTE <br /> TYP OF INSPECTION SITE COMPUTER# NUMBER •nf'il NUMBER C'�• NUMBER NUMBER <br /> / �/ PER# / "' PER# 8% PER#/0/(/T� PER# /Z <br /> Z�ks 6 — EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK TANK CONTENTS // � / /�_ //�� - / <br /> MAJOR MINOR ,: C.Be I/1- G^' c�J�e.� CJS-"z <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 g jo <br /> MONITORING SYSTEM 11 12 ✓ V <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 f ✓ ✓ <br /> TANK GAUGING 23 24 <br /> APPROVED RESPONSE PLAN 25 26 <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 2t33 SAMPLING APPROVED TANK REPAIRS UNAUTHORIZED RELEASES REPORTED SAFETY HAZARD CONDITIONS ABATED <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL W4445 <br /> FLAMMABLE VAPORS REMOVED <br /> ACCESS LOCATIONS SEALED <br /> POWER DISCONNECTED <br /> 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(M ]NOR <br /> MARK ONE) FOLLOWS: <br /> MAJOR 57 58 NO 59 <br /> VIOL. VIOL. ❑ VIOL.❑ <br /> OFFICE: INSP: , ECEIVED BY: <br /> TITLE:! PHONE:�QC �y BECK: <br />�L HUT-3 White-Original Yellow-Owner's Copy Pink-File Copy siea M <br />