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UI.-.-RGROUND TANK OFFICIAL INSPECTION RtrORT SAN JOAQUIN PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N.San Joaquin Street Mailing Address: P.O.Box 388 COUNTY NAMEIS�_Iu Stockton, CA.5201 -0388 3420 COUNTY #,_-3 SITE NAME: + C' S y- �� INSPECTION DATE: - -9 SITE ADDRESS: '7 Cj E (2--A ac Zt � CITY/STATE/ZIP �f 9 ��5--q67 CHANGES SITE YES NO TANK TANK TANK 3I TANK FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER TYPE OF INSPECTION SITE COMPUTER# NUMBER NUMBER NUMBER NUMBER rd wtIYl�, PER# PER # PER# PER# / EXP.DATE EXP.DATE EXP DATE EXP.DATE OPF� TIONAL TANK TANK CONTENTS MAJOR MINOR PERMIT TO OPERATE 1 2 CHANGE IN CONDITIONS TO OPERATE 3 4 APPROVED CONSTRUCTION 5 6 WRITTEN MONITORING PROCEDURES 7 8 APPROVED MONITORING SYSTEM 9 10 MONITORING SYSTEM 11 12 APPROVED MONITOR FREQUENCY 13 14 MONITORING RECORDS MAINTAINED 115 116 ACCESS CASING SECURED 17 118 PIPING 19 20 INVENTORY RECONCILIATION 21 22 TANK GAUGING 23 24 APPROVED RESPONSE PLAN 25 26 UNAUTHORIZED RELEASE OCCURRENCE 27 28 SAMPLING 29 30 APPROVED TANK REPAIRS 31 132 UNAUTHORIZED RELEASES REPORTED 33 34 SAFETY HAZARD 35 36 CONDITIONS ABATED 37 TEMPORARY TANK CLOSURE REMOVAL OF RESIDUAL 38 39 FLAMMABLE VAPORS REMOVED 40 ACCESS LOCATIONS SEALED 41 42 POWER DISCONNECTED 43 OWNER/OPERATOR MONITORING 44 45 77 PERMANENT TANK CLOSURE ' REMOVAL OF RESIDUAL MATERIALS 46 47 PIPING 48 49 FLAMMABLE VAPORS REMOVED 50 UNAUTHORIZED RELEASE 51 52 SAMPLING 53 54 IMPROPER ABANDONMENT 55 56 THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS SYSTEM STATUS(MUST MARK ONE) FOLLOWS: MAJOR 57❑ MINOR 58 NO 59 ❑ VOL.❑ .--._-_ VIOL. VIOL. OFFICE: INSP- 1 0 RECEIVED BYr TITLE:so(ok RE N S PHONE: BECK: HUT-3 White-Original Yellow-Owner's Copy Pink-File Copy M