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Uh_ :RGROUND TANK OFFICIAL INSPECTION RE. J <br />SAN JOAOUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 E'Weber Ave., Third Floor <br />Mailing Address: P.O. Box 388 <br />COUNTY NAME Stockton, CA 95201-0388 <br />JA►� �C)AQu 1 tV — I— COUNTY # �q <br />SITE NAME: A-i,>C.o 41io (c)O <br />INSPECTION DATE: (/� /I <br />153[�� <br />SITE ADDRESS: S - S <br />S., �a{�cJ` son Pam <br />CITY/STATE/ZIP <br />� <br />CHANGES SITE/OWNER/PERMIT? <br />YES NO <br />TANK ►7UF3p4 <br />TANK i'jo$pb <br />TANK (�pbpcl <br />TANK f-Jb$(p <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />NUMBER <br />PER # GLP <br />NUMBER <br />PER # UL <br />NUMBER <br />PER # L,(L <br />NUMBER <br />PER # <br />TYPE OF INSPECTION <br />SITE COMPUTER # <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />TANK CONTENTS ��yy )=•� <br />�.q?,ltJ <br />a'. <br />i <br />l dl QUO O O QCT <br />MAJOR MINOR!# �t1 <br />,- <br />; <br />PERMIT TO OPERATE <br />1 2 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 4 <br />APPROVED CONSTRUCTION <br />5 6 <br />WRITTEN MONITORING PROCEDURES <br />7 8 <br />APPROVED MONITORING SYS IEM <br />9 IU <br />MONITORING SYSTEM <br />11 12 <br />APPROVED MONITOR FREQUENCY <br />13 14 <br />MONITORING RECORDS MAINTAINED <br />15 16 <br />ACCESS CASING SECURED <br />17 18 <br />PIPING <br />19 20 <br />!"JVENTORY RECONCILIATION <br />21 22 <br />TANK GAUGING <br />23 24 <br />APPROVED RESPONSE PLAN <br />25 26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 28 <br />SAMPLING <br />29 30 <br />APPROVED TANK REPAIRS <br />31 32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 34 <br />SAFETY ITAZARD <br />135 136 <br />CONDITIONS ABATED <br />37 <br />TEMPORARY TANK CLOSURE <br />�, ` r <br />A ti ;•'' i <br />a: <br />< <br />i7 til•1 <br />J <br />REMOVAL OF RESIDUAL <br />38 39 <br />FLAMMABLE VAPORS REMOVED <br />40 <br />ACCESS LOCATIONS SEALED <br />41 42 <br />POWER DISCONNECTED <br />43 <br />OWNER/OPERATOR MONITORING <br />44 45 <br />PERMANENT TANK CLOSURE <br />r#,; <br />t <br />REMOVAL OF RESIDUAL MATERIALS <br />46 47 <br />PIPING <br />48 49 <br />FLAMMABLE VAPORS REMOVED <br />50 <br />UNAUTHORIZED RELEASE <br />51 52 <br />SAMPLING <br />53 54 <br />IMPROPER ABANDONMENT <br />55 56 <br />THE MARKED ITEMS <br />REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS:57 <br />---------- <br />58 <br />59 <br />— — -- -- — <br />MAJOR❑ NO <br />❑ MINOR <br />❑ <br />_ _ <br />VIOLVOL. <br />VIOL <br />OFFICE: <br />INSP:� <br />RECEIVED <br />BY: <br />TITLE: <br />PHONIL <br />1k <br />BECK: <br />` `W� <br />IIUT-3 White - Original Yellow • Owner's Copy Pink - File Copy <br />PHS 178 (4/96) <br />