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UN%wdRGROUND TANK OFFICIAL INSPECTION RE14RT <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 Stockton. CA95201.0388 <br />ass -qAM <br />f -1- 43F 3 <br />COUNTY # 24 <br />SITE NAME: / \ <br />, <br />INSPECTION DATE: <br />✓ <br />SITE ADDRESS: <br />.S <br />ITY/STATE/ZIP 57��(rh 9�- <br />CHANGES SITE/OWNER/PERMIT? YES <br />NO <br />ANK <br />TANK <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTE <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />TYPE F INSPECTION SITE COMPUTER # <br />NUM <br />NUMBER <br />NUMBER <br />NUMBER <br />`/ <br />PER # <br />PER # <br />PER # <br />PER # <br />am8aY 1 <br />EXP. DA )� <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK TANK CONTENTS <br />MAJOR MINOR <br />PERMIT TO OPERATE 1 <br />2 <br />CHANGE IN CONDITIONS TO OPERATE 3 <br />4 <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 />_ <br />PIPING 19 <br />20 <br />INVENTORY RECONCILIATION 21 <br />22 <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 33 <br />34 <br />SAFETY HAZARD 35 <br />36 <br />CONDITIONS ABATED <br />37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />W444 <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS 46 <br />47 <br />PIPING 48 <br />49 <br />FLAMMABLE VAPORS REMOVED 50mm <br />UNAUTHORIZED RELEASE 51 <br />52 <br />SAMPLING 53 <br />54 <br />IMPROPER ABANDONMENT 55 <br />56 <br />THE MARKED ITEMf REPRESENT VIOLATIONS AND MUST BE CORRECT) AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS: <br />57 58 59 <br />MAJOR MINOR NO <br />❑ ❑ <br />VIOL. VIOL. VIOL <br />OFFICE: <br />INSP40 <br />1,� <br />RECEIVED BY: <br />y <br />TITLE: ;5-XEe <br />PHONE: <br />RECK: <br />0— <br />HUT-3 Whlte-Original Yetlow-Owner's Copy Pink - File Copy 5r8e 0M <br />