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COUNTY NAME <br />SITE NAME: <br />SITE ADDRESS: <br />CHANGES SITE/OWNER/PERMIT? <br />FORM A AND/OR B SUBMITTED?- <br />TYPE OF INSPECTION SITE COMI <br />OERGROUND TANK OFFICIAL INSPECTIONWORT <br />SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N. San Joaquin Street <br />Melling Address: P.O. Bax 388 <br />Stockton, CA 95201.0388 COUNTY # <br />488-3420 <br />/� U C.,:/n1 /7'----S <br />OPERATIONAL TANK <br />PERMIT TO OPERATE <br />CHANGE IN CONDITIONS TO OPERATE <br />APPROVED CONSTRUCTION <br />WRITTEN MONITORING PROCEDURES <br />APPROVED MONITORING SYSTEM <br />MONITORING SYSTEM <br />APPROVED MONITOR FREQUENCY <br />MONITORING RECORDS MAINTAINED <br />ACCESS CASING SECURED <br />PIPING <br />INVENTORY RECONCILIATION <br />TANK GAUGING <br />APPROVED RESPONSE PLAN <br />UNAUTHORIZED RELEASE OCCURRENCE <br />SAMPLING <br />APPROVED TANK REPAIRS <br />UNAUTHORIZED RELEASES REPORTED <br />SAFETY HAZARD <br />CONDITIONS ABATED <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />INSPECTION DATE: 3%e <br />/Pfd CITY/STATE/ZIPL� LE/ <br />YES NO TANK tt f TANK I TANK <br />COMPUTER COMPUTER COMPUTER <br />NUMBER /a,00c' NUMBER NUMBER <br />R # PER # 0/S:y PER # PER # <br />Y <br />► EXP. DATE EXP. DATE EXP, DATE <br />TANK CONTENTS '- >""+ s' <br />a9 ? <br />MAJOR MINOR <br />1-17 2 �✓' <br />3 4_......._,- <br />7 8 <br />9 10 <br />11 12 <br />13 14 - <br />- <br />17 18 <br />19 20 <br />21 22 <br />23 24 <br />25 26 <br />27 2B <br />29 30 <br />31 32 <br />33 34 <br />35 36 <br />TANK <br />COMPUIFER <br />NUMBER <br />PER # <br />EXP. DATE <br />M■ <br />38 <br />39 <br />40 <br />� °. <br />41 <br />42 <br />46 47 <br />43 <br />44 <br />45 <br />48 49 <br />50 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />PIPING <br />FLAMMABLE VAPORS REMOVED <br />UNAUTHORIZED RELEASE <br />SAMPLING <br />IMPROPER ABANDONMENT <br />�� �� ' <br />� °. <br />v%4 <br />46 47 <br />48 49 <br />50 <br />51 52 <br />53 54 <br />55 56 <br />THE MARKED ITEMS <br />FOLLOWS: <br />REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />MAJOR 57 MINOR 56 <br />VIOL. VIOL. ❑ <br />NO 59 <br />VIOL. ❑ <br />OFFICE: <br />INSP. <br />TITL>T: �? �. ��.�` <br />RECEIVED B , <br />P O E:� RECK: <br />AUT -3 White - Original Yellow • Owner's Copy_ _ Pink - File Copv <br />5/86 OM <br />