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1 • UOGROUND TANK OFFICIAL INSPECTION R14k!T 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 OUNTY # SITE NAME: !. INSPECTION DATE: SITE ADDRESS: 3 41 ECITY/STATE/ZIP �- CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK TAN 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 CONTENTS x , MAJOR MINOR r 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 12 APPROVED MONITOR FREQUENCY 13 14 MONITORING RECORDS MAINTAINED 15 16 ACCESS CASING SECURED 17 18 PIPING 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 REMOVAL OF RESIDUAL 38 39 FLAMMABLE VAPORS REMOVED 40 ACCESS LOCATIONS SEALED 41 42 POWER DISCONNECTED 43 OWNER/OPERATOR MONITORING 44 45 � 3 PERMANENT TANK CLOSURE - y REMOVAL OF RESIDUAL MATERIALS 46 147 PIPING 48 149 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: -z- 57 57 58 59MAJOR NO - VIOL. ❑ VIOLL..R ❑ VOL. 444 ❑ OFFICE: INSP% C�M RECEIVED TITLE: PHONE: BECK: 441 IT-1 White-Orininal Yellow-Owner's Cnnv Pink-Fila Cnnv