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U* RGROUND TANK OFFICIAL INSPECTION FART <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 COUNTY <br />468-3420 <br />SITE NAME: INSPECTION DATE: <br />SITE ADDRESS: CITY/STATE/ZIP <br />CHANGES SITE/OW ER/PERMIT?' YES NO TANK TANK TANK NK <br />FORM A AND/OR B SUBMITTED? COMPUTE COMPUTER COMPUTER COMPUT <br />TYPE -OF INSPECTION SITE COMPUTER # NUMBEq NUMBER NUMBER NUMBER <br />PER # PER # PER # PER # <br />EXP. DATE EXP. DATE_ EXP. DATE EXP. DATE <br />OPERAnONAL TANK <br />PERMIT TO OPERATE <br />CHANGE IN CONDITIONS TO OPERATE <br />APPROVED CONSTRUCTION <br />WRITTEN MONITORING PROCEDURES <br />APPROVED MONITORING SYSTEM <br />MONITORING SYSTEM <br />APPROVED MONITOR FREQUENCY <br />MONITORING RECORDS MAINTAINED <br />ACCESS CASING SECURED <br />PIPING <br />INVENTORY RECONCILIATION <br />TANK GAUGING <br />APPROVED RESPONSE PLAN <br />UNAUTHORIZED RELEASE OCCURRENCE <br />SAMPLING <br />APPROVED TANK REPAIRS <br />UNAUTHORIZED RELEASES REPORTED <br />SAFETY HAZARD <br />CONDITIONS ABATED <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />TANK CONTENTS <br />„ <br />.,�'� <br />i;�WX <br />MAJOR MINOR <br />48 <br />49 <br />FLAMMABLE VAPORS REMOVED <br />50 <br />1 2 <br />51 <br />52 <br />SAMPLING <br />a <br />3 4 <br />5 6 <br />55 <br />156 <br />7 8 <br />9 10 <br />11 12 <br />13 14 <br />15 16 <br />17 18 <br />19 20 <br />21 22 <br />23 24 <br />25 26 <br />27 28 <br />29 30 <br />_..... ,. <br />31 32 <br />_.... <br />_... <br />33 34 <br />_ .. . <br />35 36 <br />37 <br />R, <br />MW <br />38 <br />40 <br />q43 <br />41 <br />44 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />46 47 <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 />156 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE.GQRRECTED AS <br />;YSTEM STATUS (MUST MARK ONE) <br />57 -- <br />MAJOR MINOR 58 NO 59 <br />VIOL. ❑ VIOL. ❑ VIOL. <br />OFFICE: INSP- ., 7RECEIVED BY: <br />7XI I/ 14f- rj <br />/ A Ko,+-,, &0 <br />TITLE: PHO E: /RECK: <br />6. <br />HUT -3 White - Or'Cinal Yellow -Owner's Coov Pink - File Coov c _,. <br />