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UAGROUND TANK OFFICIAL INSPECTION R <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, C8 -34A 9522001-0388 COUNTY # <br />46 <br />OFFICE: INSP- <br />RECEIVED BY: <br />TITLE: ry e PHONE: BECK: <br />HL IT -3 White-OrIginal Yellow -Owner's Copy Pink - File Copv <br />SITE NAME: 0 _/ j <br />-b/ vcr <br />INSPECTION DATE: <br />7— 2,7 j <br />SITE ADDRESS:0 Z <br />,7A <br />CITY/STATE/ZIP <br />CHANGES SITE/OWNER/PERMIT? <br />YES <br />NO <br />TANK <br />TANK <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />TYPE OF INSPECTION ISITE COMPUTER # <br />NUMBER <br />NUMBER <br />NUMBER <br />NUMBER <br />PER # <br />PER # <br />PER # <br />PER # <br />76 <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERAAONAL TANK <br />TANK CONTENTS <br />MAJOR MINOR <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 />WRITTEN MONITORING PROCEDURES <br />7 <br />8 <br />APPROVED MONITORING SYSTEM <br />9 <br />10 <br />MONITORING SYSTEM <br />11 <br />12 <br />APPROVED MONITOR FREQUENCY <br />13 <br />14 <br />MONITORING RECORDS MAINTAINED <br />15 <br />16 <br />ACCESS CASING SECURED <br />17 <br />18 <br />PIPING <br />19 <br />20 <br />INVENTORY RECONCILIATION <br />21 <br />22 <br />TANK GAUGING <br />23 <br />24 <br />APPROVED RESPONSE PLAN <br />25 <br />26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 <br />28 <br />SAMPLING <br />29 <br />30 <br />APPROVED TANK REPAIRS <br />31 <br />32 <br />------ <br />UNAUTHORIZED RELEASES REPORTED <br />33 <br />34 <br />SAFETY HAZARD <br />35 <br />136 <br />CONDITIONS ABATED <br />37 <br />TEMPORARY TANK CLOSURE <br />g <br />REMOVAL OF RESIDUAL <br />38 <br />FLAMMABLE VAPORS REMOVED <br />-.39 <br />40 <br />ACCESS LOCATIONS SEALED <br />41 <br />424 <br />POWER DISCONNECTED <br />43 <br />OWNER/OPERATOR MONITORING <br />44 <br />45� <br />PERMANENT TANK CLOSURE <br />JBM <br />REMOVAL OF RESIDUAL MATERIALS <br />46 <br />47 <br />PIPING <br />48 <br />49 <br />FLAMMABLE VAPORS REMOVED <br />50 <br />MM <br />UNAUTHORIZED RELEASE <br />51 <br />52 <br />SAMPLING <br />153 154 <br />IMPROPER ABANDONMENT <br />155 156 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS <br />57 58 <br />59 <br />MAJOR o MINOR NO <br />El <br />rz-f <br />VIOL. VIOL. VIOL. <br />LJ <br />OFFICE: INSP- <br />RECEIVED BY: <br />TITLE: ry e PHONE: BECK: <br />HL IT -3 White-OrIginal Yellow -Owner's Copy Pink - File Copv <br />