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UNIkGROUNO TANK OFFICIAL INSPECTION REW <br /> SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALT J DIVISION <br /> 304 E.Weber Ave.,Thi, Floor <br /> Meiling Address:P.O.Box Me <br /> COUNTY NAME Stockton,CA 96201-0388 COUNTY # <br /> 468.3420 <br /> SITE NAME: F R ck t INSPECTION DATE: <br /> SITE ADDRESS: 1 J f 11 ` CITY/STATE/ZIP <br /> ;,4 Xr7W o r <br /> CHANGES SITE/OWNE /PERMIT? YES NO TANK TANK TANK TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> NUMBER NUMBER NUMBER NUMBER <br /> TYPE OF INSPECTION SITE COMPUTER/ PER N PER PER M PER # <br /> �j EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK tore cortrewrs Q "�.� . ... { 1. <br /> MAJOR I 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 MONI TORING SYSI EM 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 PLAT) 25 -;iii— <br /> UNAUTHORIZED <br /> 8UNAUTHORIZED RELEASE OCCURRENCE 27 28 <br /> .. ._._. <br /> SAMPLING 29 3D <br /> APPROVED TANK REPAIRS 31 32 <br /> UNAUTHORIZED RELEASES REPORTED 33 34 <br /> SAFETY HAZARD 35 36 <br /> CONDITIONS ABATED 37 <br /> e <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL V4445 <br /> FLAMMABLE VAPORS REMOVED <br /> ACCESS LOCATIONS SEALED <br /> POWER DISCONNECTED <br /> OWNER/OPERATOR MONITORING <br /> PERMANENT TANK CLOSURE <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 MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONE) FOLLOWS: <br /> 57 58 59 <br /> NO <br /> VIOL..R ❑ VIOLL..R ❑ VOL.❑ __ __ <br /> OFFICE: INSP: %ECZ11Y <br /> TITLE: '/ J E: z RECK <br /> IIIIT-3 Whlln 06011 l Yellow-Owner's Copy Pink-File Coopv <br /> PHS 178 (4196) <br />