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UORGROUND TANK OFFICIAL INSPECTION R&T <br /> SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENT,IL HEALTH PDIVISION <br /> 304 E. eber Ave.,Third loor <br /> Mailing Atldress:P.O.Bon 388 <br /> COUNTY NAME Stockton,CA 95201-0388 COUNTY # <br /> 4883420 <br /> SITE NAME: INSPECTION DATE: <br /> SITE ADDRESS: �� 'F CITY/STATE/ZIP �� � <br /> CHANGES SITE/OWNER/PERMIT? YES NO T K TANK TANK TANK <br /> FORM A AND/OR 8 SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> NUMBER NUMBER NUMBER NUMBER <br /> TYPE OF INSPECTION SITE COMPUTER+1 PER ff PER # PER a PER R <br /> EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATI NAL TANK mrm cor+reots t'(.; i,� I r�?ii °t��' <br /> MAJOR MINOR T=.s ..'�. L '.11 t 14 <br /> 5' == <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 IT 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 /> APPROVED TANK REPAIRS 31 32 _ <br /> UNAUTHORIZED RELEASES REPORTED 33 34 <br /> SAFETY HAZARD 35 36 <br /> CONDITIONS ABATED 37 <br /> TEMPORARY TANK CLOSURE �� l� < �; 4H4ja^itl <br /> REMOVAL OF RESIDUAL 3B 39 <br /> FLAMMABLE VAPORS REMOVED 40 <br /> ACCESS LOCATIONS SEALED 41 42 <br /> POWER DISCONNECTED 43 <br /> OWNER/OPERATOR MONITORING 44 45 <br /> I <br /> ,1 <br /> x1 1 <br /> PERMANENT TANK CLOSURE M� . � ,'"', ,:fir OWN :,T <br /> REMOVAL OF RESIDUAL MAI ERIALS 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 ND MUST BE CQRRECTED AS <br /> SYSTEM STATUS(MU51 MARK ONE) FOLLOWS:+ ��---- -- —'F0�° <br /> /'1 -- <br /> 58 NO 59 <br /> p MA.OR El 57 VIOL.R ❑ VOL.❑ — - <br /> OFFICE: INSRECEIVED BY: <br /> TfJLh 4 PHONE: BECK: <br /> I II J T-3 White-Orlglnal Yellow-Owner's Copy Pink-File Copv�w <br /> PHS 178 (4/96) <br />