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UN AGROUND TANK OFFICIAL INSPECTION RE%/RT <br />SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N. San Joaquin Street <br />Mailing Address: P.O. Box 388 <br />COUNTY NAME Stockton, CA 95201-0388 COUNTY # 7 <br />468-3420 <br />SITE NAME:E F <br />G <br />INSPECTION DATE: <br />SITE ADDRESS: <br />XA�5 <br />-CIT/S ATE/ZIP <br />C/ -7- <br />CHANGES <br />CHANGES SITE <br />YES <br />NO <br />TANK 2TANK <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTE <br />COMPUTER (✓/ <br />COMPUTEI5� <br />MPUTER <br />NUMBE <br /># <br />NUM <br />NUMBER <br />UMBER <br />TYP F INSPECTION <br />SITE COMPUTER # <br />M. <br />PER <br />RjR <br />PE <br />PER # <br />PER # <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />P. DATE <br />OPERATIONAL TANK <br />TANK CONTENTS <br />MAJOR MINOR <br />- <br />PERMIT TO OPERATE <br />1 <br />2 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 <br />4 <br />APPROVED CONSTRUCTION <br />5 <br />6 <br />WRITTEN MONITORING PROCEDURES <br />7 <br />8 <br />APPROVED MONITORING SYSTEM <br />9 <br />10 <br />MONITORING SYSTEM <br />11 <br />12 <br />APPROVED MONITOR FREQUENCY <br />13 <br />14 <br />MONITORING RECORDS MAINTAINED <br />15 <br />16 <br />ACCESS CASING SECURED <br />17 <br />18 <br />PIPING <br />19 <br />20 <br />- <br />t <br />INVENTORY RECONCILIATION <br />21 <br />22 <br />_ <br />TANK GAUGING <br />23 <br />24 <br />APPROVED RESPONSE PLAN <br />25 <br />26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 <br />28 <br />SAMPLING <br />29 <br />30 <br />APPROVED TANK REPAIRS <br />31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 <br />34 <br />SAFETY HAZARD <br />35 <br />36 <br />CONDITIONS ABATED <br />37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />W43 <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />46 <br />47 <br />PIPING <br />FLAMMABLE VAPORS REMOVED <br />48 <br />50 <br />49 <br />G{ <br />UNAUTHORIZED RELEASE <br />51 <br />52 <br />SAMPLING <br />53 <br />54 <br />vid <br />%Y- 5 3 r <br />IMPROPER ABANDONMENT <br />55 <br />56 <br />.. g U400 Cmv <br />THE MARKED ITEMS REPRE NT VIOLATIONS AND M11ST BE CORRECT A <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS: <br />3 oo <br />57 58 <br />59 <br />S <br />MAJOR MINOR NO <br />❑ ❑ <br />- <br />VIOL VIOL. VtOL. <br />OFFICE: <br />INS i <br />RECEIVED BY: <br />„, <br />, CkcT <br />/ <br />Z <br />TITLE: S <br />PHONE: �T�! flJ� <br />RECK: <br />HUT -3 White -Original Yellow - Owner's Copy Pink - File Copv 5/m OO . <br />N <br />