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UI,.,�RGROUND TANK OFFICIAL INSPECTION R.,,/RT <br /> SAN JOAOUIN 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: — .L INSPECTION DATE: <br /> b P)t ✓ '�—� <br /> SITE ADDRESS: -4� CITY/STATE/ZIP -- <br /> I c,L. C� <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK ! <7007 TANK TANK TANK <br /> FORM A AND/OR B SUBMITTED? COMPUfE� <br /> TYPE OF INSPECTION SITE COMPUTER# �. <br /> COMPUTER COMPUTER COMPUTER <br /> NUMBER ' }��o/ NUMBER NUMBER NUMBER <br /> PER # PER# PER# PER# <br /> EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK T KCONTENTS <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 26 <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 28 <br /> SAMPLING 29 30 <br /> PPROVED 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 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 r55 <br /> 47 <br /> PIPING 49 <br /> FLAMMABLE VAPORS REMOVED <br /> UNAUTHORIZED RELEASE 52 <br /> SAMPLING 54 <br /> IMPROPER ABANDONMENT 56 <br /> THE MARKED ITEMS REPRESENT VIOLATIO S AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONE) FOLLOWS: tip?)) t+ 1 L CY'161 T <br /> 757 7 <br /> VIOLOR ❑ VIOL. 11 VIOL.El III Lp Lit 4 A4 <br /> _ <br /> OFFICE: INSP: �JcJL�y C4, RECEIVED BY: <br /> l <br /> TITLE: i1 S PHONE PECK: <br /> HUT-3 White-Original Yellow-Owner's Copy Pink-File Copy 5i88 n M <br />