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RGROUND TANK OFFICIAL INSPECTION &RT <br />• SAN JOA©UIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N. San Joaquin Street <br />Mailing Address: P.O. Box 388 <br />COUNTY NAME <br />Stockton, 4CA 420@1•o3se <br />SITE NAME: <br />COUNTY # <br />INSPECTION DATE: - /ZIF <br />SITE ADDRESS:1151 / �z� �� GITYISTATE/ZIPG ,r <br />SHANGES SITE/ OWNER/ PERMIT/? YES NO TANK e�6_ f TANK TANK <br />=ORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER <br />NUMBER lv,uvv NUMBER NUMBER <br />TYPE OF INSPECTION SITE COMPUTER # PER # PER # PER # <br />p� 7 IF 7 –_75 EXP. DATE EXP. DATE EXP. DATE <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 />TANK CONTENTS <br />41 42 <br />43 <br />44 45 <br />MAJOR MINOR <br />2 <br />/ <br />a� <br />3 4 <br />5 6 <br />7 8 <br />9 10 <br />11 12 <br />13 14 <br />16 <br />17 18 <br />19 20 <br />21 22 <br />23 24 <br />25 26 <br />27 28 <br />29 30 <br />31 32 <br />33 34 <br />35 36 <br />37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />38 39 <br />40 <br />41 42 <br />43 <br />44 45 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />PIPING <br />FLAMMABLE VAPORS REMOVED <br />UNAUTHORIZED RELEASE <br />SAMPLING <br />IMPROPER ABANDONMENT <br />46 47 <br />48 49 <br />50 <br />91 <br />51 52 <br />53 54 <br />55 <br />56 <br />SYSTEM STATUS (MUST MARK ONE) <br />57 58 <br />MAJOR MINOR <br />VIOL. VIOL. ❑ <br />59 <br />NO <br />VIOL. ❑ <br />TANK <br />COMPUTER <br />NUMBER <br />PER # <br />EXP. DATE <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />FOLLOWS: !_ /t_17 <br />OFFICE: INSP: RECEIVED B <br />TITLE: .4 +�� PHO E: BECK: <br />HUT -3 White - Original Yellow - Owner's Copy Pink - File Copv Sis[3" <br />