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L .ERGROUND TANK OFFICIAL INSPECTION r._,JORT SAN JOAQUIN PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N.San Joaquin Street Mailing Address: P.O.Box 388 COUNTY NAME Stockton,CA 95201-0388 COUNTY # 468-3420 SITE NAME: i INSPECTION DATE: SITE ADDRESS: //��/� �1 CITY/STATE/ZIPA� /7�Zyz> CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK TANK TANK FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER TYPE OF INSPECTION SITE COMPUTER# NUMBER NUMBER NUMBER NUMBER PER# PER# PER # PER # EXP.DATE EXP.DATE EXP.DATE EXP.DATE OPERATIONAL TANK TANK CONTeNrs 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 11 112 APPROVED MONITOR FREQUENCY 13 114 MONITORING RECORDS MAINTAINED 15 116 ACCESS CASING SECURED 17 18 WIPING 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 32 UNAUTHORIZED RELEASES REPORTED 33 34 SAFETY HAZARD 35 36 CONDITIONS ABATED 37 TEMPORARY TANK CLOSURE � ; .a REMOVAL OF RESIDUAL 38 39 FLAMMABLE VAPORS REMOVED 40 ACCESS LOCATIONS SEALED 41 42 POWER DISCONNECTED 43 OWNER/OPERATOR MONITORING 44 45 PERMANENT-T*NIE—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: SSE 57 58 59 MAJOR 119U — VIOL. ❑ VIOLL..R ❑ VOL.❑ - - - --- - - - --- OFFICE: INSP:I ` RECEIVED BY: �t� TITLE: PHONE: RECK: HUT-3 White-Original Yellow-Owner's Copy Pink-File Copv 5188 n m