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*RGROUND TANK OFFICIAL INSPECTION ROORT <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 <br />ACOUNTY # <br />i:C_�]A7n <br />SITE NAME: --��Q <br />INSPECTION DATE:.C�_S <br />SITEADDRESS: 3 5 1 <br />�� Vd <br />CITY/STATE/ZIP q s 3� / <br />CHANGES SITE <br />YES <br />NO TANK <br />TANK TANK O <br />TANK !� <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />COMPUTER COMPUTER <br />COMPUTER <br />TYPE OF INSPECTION SITE COMPUTER # <br />NUMBER <br />NUMBER NUMBER <br />NUMBER <br />PER # U1, _,S PER # �IL, PER # x - 1_ <br />PER # Z>i(f� <br />�1 <br />1 T i <br />EXP. DATE <br />EXP. DATE EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />TANK CONTENTS <br />MAJR <br />PERMIT TO OPERATE <br />1CHANGE <br />IN CONDITIONS TO OPERATE <br />3APPROVED <br />CONSTRUCTION <br />5 <br />WRITTEN MONITORING PROCEDURES <br />7 <br />8 <br />APPROVED MONITORING SYSTEM <br />9 <br />10 <br />MONITORING SYSTEM <br />11 <br />12 <br />�/... <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 />__ ..__._ __,,_...._ ._ _ ... _,._. _.__. _ . _.------- _...__ <br />TANK GAUGING <br />23 <br />24_.. <br />- <br />APPROVED RESPONSE PLAN <br />25 <br />26 � <br />� .. .......... _ --------- ..a.... <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 <br />28 <br />SAMPLING <br />29 <br />30 <br />APPROVED TANK REPAIRS <br />31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 <br />34 <br />SAFETY HAZARD <br />35 <br />36 <br />CONDITIONS ABATED <br />37 <br />TEMPORARY TANK CLOSURE'` <br />REMOVAL OF RESIDUAL <br />38 <br />39 <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 />49 <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 />57 58 <br />MAJOR❑VIOL. MINOR❑ NO <br />59 <br />❑ <br />------ — <br />VIOVIOL. <br />OFFICE: <br />INSP: <br />RECE D B <br />F <br />' <br />TIT <br />PHONE: <br />01 <br />CK: <br />Ht IT -3 White - Orieinal Yellow - Owner's Coov Pink - File Cnnv <br />