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O&GROUND TANK OFFICIAL INSPECTION ROT SAN JOAQUIN PUBLIC HEALTH SERVICES ENVIRONMENTWALHEA4hH DIVISION Mailing Address:P.O.Box 388 COUNTY NAME Stockton,CA 95201-0388 COUNTY # 488-3420 SITE NAME: 1 INSPECTION DATE 9 SITE ADDRESS: CITY/STATE/ZIP CHANGES SITE YES NO K TANK TANK TANK FORM AAND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER NUMBER NUMBER NUMBER NUMBER TYPE OF INSPECTION SITE COMPUTER# PER of PER# PER # PER# EXP.DATE EXP.DATEy EXP.DATE EXP.DATE TANK CONTENTS OPERATIONAL TANK MAJOR MINOR PERMIT TO OPERATE 1 2 CHANGE IN CONDITIONS TO OPERATE 3 4 APPROVED CONSTRUCTION 5 6 _ WRITTEN MONITORING PROCEDURES 7 B APPROVED MONNORING SYSTEM 9 10 MONITORING SYSTEM 11 12 APPROVED MONITOR FREQUENCY 13 14 MONITORING RECORDS MAINTAINED 15 16 ACCESS CASING SECURED 17 18 PIPING 19 20 INVENTORY RECONCILIATION 21 22 TANK GAUGING 23 24 APPROVED RESPONSE PLAN 25 26 UNAUTHORIZED RELEASE OCCURRENCE 27 28 SAMPLING 29 31) _. APPROVED TANK REPAIRS 31 32 _ UNAUTHORIZED RELEASES REPORTED 33 34 SAFETY I IAZARO 35 36 CONDITIONS ABATED 37 TEMPORARY TANK CLOSURE MET REMOVAL OF RESIDUAL 38 39 FLAMMABLE VAPORS REMOVED 40 ACCESS LOCATIONS SEALED 41 42 POWER DISCONNECTED 43 OWNER/OPERATOR MONITORING 44 45 i PERMANENT TANK CLOSURE #° REMOVAL OF RESIDUAL MATERIALS 46 47 PIPING 48 49 FLAMMABLE VAPORS REMOVED 50 UNAUTHORIZED RELEASE 5t 52 SAMPLING 53 54 IMPROPER ABANDONMENT 55 56 THE MARKED ITEMS REPRESENT VIOLAT,IIONNS,AND MUST BE CORRECTED AS SYSTEM STATUS(MUST MARK ONE) FOLLOWS:57 58 59 �40 MA, VIOLOR MIN❑ MOOR ❑ NO VIOL.❑ lk OFFICE: INSP RECEIVED BY: TITLE: PHONE: HECK: I IUT-3 While-Original Yellow-Owner's Copy Pink-File Copv PHS 178 (4196)