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•' ` UORGROUND TANK OFFICIAL INSPECTION F&RT <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,CA 95201-0388 COUNTY OUNTY # <br /> SITE NAME: f INSPECTION DATE: <br /> SITE ADDRESS: CITY/STATE/ZIP ::=4 <br /> CHANGES SITE YES NO TANK .t- / TANK e Z TANK rt 3 TANK 7 <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 /> apv�_1_11 F EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK TMK CON N <br /> MAJOR 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 2-6 <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 ABATED 37 <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL R4445 <br /> 9 <br /> FLAMMABLE VAPORS REMOVED <br /> ACCESS LOCATIONS SEALED 2 <br /> POWER DISCONNECTED 3 <br /> OWNER/OPERATOR MONITORING <br /> PERMANENT TANK CLOSURE »f, <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 FAUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONE) FOLLOWS: --aG �GdU <br /> MAJOR 57 MINOR 58 NO 59 <br /> VIOL. VIOL. ❑ VIOL.❑ <br /> OFFICE: INSP: jG RECEIVED BY:,,,e0rkA! <br /> �� /� ZI9/ tiIA✓q C- <br /> /`�'�-- s->ac�Ter! C¢ 956 <br /> TITLE: LG s PHONE RECK: <br /> HUT-3 White-Original Yellow-Owner's Copy Pink-File Copy sre8 ©M <br />