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' JERGROUND TANK OFFICIAL INSPECTION, .r)ORT <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 OUNTY # <br />SITE NAME: UG� <br />69 INSPECTION DATE: /Z—/3� <br />( <br />9 <br />SITE ADDRESS:111;1'1? <br />���„ / <br />CITY/STATE/ZIP ���� <br />7 <br />CHANGES SITE <br />YES NO <br />TANK <br />TANK <br />TANK 0`4 <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />NUMBER /p� <br />COMPUTER <br />NUMBER /p A <br />COMPUTER <br />NUMBER /o <br />COMPUTER <br />NUMBER <br />TYPE OF INSPEC ION <br />SITE COMPUTER # <br />_ <br />��—/ <br />GJ <br />PER # !/�L <br />PER # !i/L-f <br />PER # S��E <br />PER # <br />G <br />/ <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />TANK CONTENTS <br />- <br />MAJOR MINOR <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 SYSTEM <br />9 10 <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 />INVENTORY RECONCILIATION <br />21 22 — <br />�! <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 HAZARD <br />35 36 <br />CONDITIONS ABATED <br />37 <br />TEMPORARY TANK CLOSURE <br />., . <br />REMOVAL OF RESIDUAL <br />38 139 <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 />-. <br />�... <br />REMOVAL OF RESIDUAL MATERIALS <br />46 47 <br />PIPING <br />48 49 <br />FLAMMABLE VAPORS REMOVED <br />UNAUTHORIZED RELEASE <br />52 <br />SAMPLING <br />54 <br />U56 <br />IMPROPER ABANDONMENT <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS: <br />�� <br />_ �.c <br />MAJOR 57 MINOR 58 NO <br />E]VIOL. ❑ <br />59 <br />VIOL. VIOL. <br />OFFICE: <br />INSP: <br />RECEIVED BY- _ <br />TITLE: �. E s <br />ONE: BECK: <br />HU I —3 White - Or,einal Yellow - Owner's Copy Pink - File Copv <br />