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UIORGROUND TANK OFFICIAL INSPECTION RI&T <br /> ' SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 364 E.Weber Ave.,Third Floor <br /> Mailing Address:P.O,Box 388 <br /> COUNTY DAME Stockton.CA 95201-vasa COUNTY <br /> # <br /> 468-3420 <br /> SITE NAME: <br /> INSPECTION DATE: <br /> SITE ADDRESS: 09 � k � ` CITY/STATE/ZIP <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK TAMC TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> TYPE OF INSPECTION SITE COMPUTER NUMBER NUMBER NUMBER NUMBER <br /> i PER PER # PER # PER # <br /> EXR DATE EXP DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK TANK CONTEWS <br /> mA,3oi1 <br /> PERMIT TO OPERATE , 2 <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 g <br /> WRITTEN MONITORING PROCEDURES 7 J�2 APPROVED MONITORING SYSTEM 9MONITORING SYST EM 1 1 APPROVED MONITOR FREOUENCY 13 MONITORING RECORDS MAINTAINED f5 <br /> ACCESS CASING SECURED 17 18 <br /> PIPING 19 20 <br /> INVENTORY RECONCILIATION 21 22 <br /> TANK GAUGING <br /> 23 24 <br /> APPROVED RESPONSE PLAN 25 26 <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 28 <br /> SAMPLING 29 30 <br /> APPROVED TANK REPAIFJS 31 32 <br /> UNAUTHORIZED RELEASES REPORTED 33 34 <br /> SAFETY IIAZARD 35 36 <br /> t <br /> CONDITIONS ABATED 37 <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL 38 39 <br /> FLAMMABLE VAPORS REMOVED 40 <br /> ACCESS LOCATIONS SEALED 41 42 <br /> POWER DISCONNECTED m 43 <br /> OWNER/OPERATOR MONITORING 44 45 <br /> PERMANENT TANK CLOSURE ? <br /> �� :•b3 1i � <br /> REMOVAL OF RESIDUAL MATERIALS 4G 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 /> SYSTEM STATUS(MUSE MARK ONE <br /> THE MARKED ITE AS REPRE T VIOLATIONS AND MUST BE CORRECTED AS <br /> r <br /> FOLLOWS: <br /> MAJOR 57 MINOR 58 NO 59 ---. __—.--_-� <br /> VIOL ❑ VIOL. ❑ VIOL.❑ <br /> OFFICE: INSP CEIVED BY• <br /> TITLE: I! 11G lf?r� PHON FLECK, <br /> F IUT-3 White-Original Yetlow•Owner'q Copy Pink.File Copv <br /> PHS 179 (4/96) <br />