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UK__RGROUND TANK OFFICIAL INSPECTION RE. _8T <br />SAN JOAOUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEAITTH DIVISION <br />304 E. Weber Ave., hird Floor <br />Mailing Address: P.O. Box 388 <br />COUNTY NAME 5a4t )-C, Esq L[ Ciro Stockton3420�� 03� f,OUNTY <br />SITE NAME:INSPECTION <br />7h� c.Co r� <br />DATE: <br />SITE ADDRESS: .53 0'r <br />yp` tp .5�t, <br />CITY/STATE/ZIP <br />S;4 ' v <br />CHANGES SITE/OWNER/PERMIT? <br />YES <br />NO <br />TANK <br />TANK --1, <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />NUMBER <br />NUMBER <br />NUMBER <br />NUMBER <br />TYPE OF INSPECTION <br />SITE COMPUTER # <br />r 0 Ld) h,.¢._ <br />PER <br />PER * <br />PER a <br />PER s <br />EXP. DATE <br />EXP. DATE <br />EXP`. DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />TANKCONTENTS <br />— <br />MR INOAJOMR <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 />l'►15 tA�� �O� <br />WRITTEN MONITORING PROCEDURES <br />7 <br />8 <br />base <br />APPROVED MONITORING SYSIEM <br />9 <br />10 <br />J <br />//y1 <br />MONITORING SYSTEM <br />APPROVED MONITOR FREQUENCY <br />11 <br />13 <br />112 <br />14 <br />1 re <br />" 0�9CG <br />J y <br />AM Sic. <br />MONITORING RECORDS MAINTAINED <br />15 <br />16 <br />C� 1's <br />ACCESS CASING SECURED <br />PIPING <br />17 <br />19 <br />18 <br />20 <br />ccc& <br />!NVENTORY RECONCILIATION <br />21 <br />22 <br />rG`�L l! <br />TANK GAUGING <br />APPROVED RESPONSE PLAN <br />23 <br />25 <br />24 <br />26 <br />........... <br />r 0 .0 - <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 <br />28 <br />aitlw <br />SAMPLING <br />29 <br />30 <br />APPROVED TANK REPAIFIS <br />31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 <br />134 <br />SAFETY HAZARD <br />35 <br />136 <br />CONDITIONS ABATED <br />37 <br />//{7,p� <br />1—� • l ����i �s v�J�� <br />,. <br />TEMPORARY TANK CLOSUR <br />'X <br />, <br />REMOVAL OF RESIDUAL* <br />38 <br />139 <br />FLAMMABLE VAPORS REMOVED <br />40 <br />ACCESS LOCATIONS SEALED <br />41 <br />42 <br />POWER DISCONNECTED <br />43 <br />OWNER/OPERATOR MONITORING <br />44 <br />45 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />46 <br />147 <br />PIPING <br />48 <br />149 <br />FLAMMABLE VAPORS REMOVED _ <br />50 <br />UNAUTHORIZED RELEASE <br />51 <br />52 <br />SAMPLING <br />53 <br />54 <br />IMPROPER ABANDONMENT <br />55 <br />56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS: <br />— - ---- <br />MAJOR57 MINOR 8 NO 59 <br />❑ VIOL. VIOL. ❑ <br />41V 1) 6 a 77S ` <br />- - e _- - -. __ if <br />VIOL. <br />OFFICE: <br />INSP <br />RFGOVED <br />B� Y* <br />P,_4 <br />Z__ <br />I I TLE: <br />S <br />(', C� �, <br />PHONE: <br />JZsi <br />HUT -3 While - Original Yellow - Owner's Copy Pink - File Copy <br />PHS 178 (4/96) <br />i <br />41 <br />