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COUNTY NAME <br />SITE NAME: A <br />ori <br />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 />Stockton, CA 95201-0388 <br />468-3420 <br />COUNTY # <br />INSPECTION DATE-, <br />HUT -3 White - Original Yellow - Owner's Copy Pink - File Coov 5/88 0 nn <br />1P 7' <br />SITE ADDRESS: <br />CITY/STATE/ZIP <br />J <br />CHANGES SITE/OWNER/PERMIT? V YES <br />NO <br />TAN oz, TANK <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />CO PUTEP COMPUTER <br />NU BER NUMBER <br />PER# / 710�0 <br />COMPUTER <br />NUMBER <br />COMPUTER <br />NUMBER <br />TYPE OF INSPECTIJDN <br />COMPUTER # <br />C <br />PER # <br />PER # <br />PER # <br />EXP. DATE EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPER ATIO 4AL TANK <br />TANK <br />CONTENTS <br />MAJOR <br />MINOR <br />PERMIT TO OPERATE <br />1 <br />2 <br />CHANGE IN CONDITIONS TO OPERATE 3 <br />4 <br />APPROVED CONSTRUCTION <br />5 <br />6 <br />WRITTEN MONITORING PROCEDURES 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 />----------- ------ ---- <br />APPROVED RESPONSE PLAN <br />25 <br />26 <br />UNAUTHORIZED RELEASE OCCURRENCE 27 <br />28 <br />SAMPLING <br />29 <br />30 <br />-------------------- <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 />M43 <br />---- ------ <br />OWNER/OPERATOR MONITORING <br />44 <br />45 <br />-- --- - <br />PERMANENT TANK CLOSURE <br />mvii <br />gg <br />REMOVAL OF RESIDUAL MATERIALS <br />46 <br />47 <br />PIPING <br />48 <br />49 <br />FLAMMABLE VAPORS REMOVED <br />50 <br />WE, <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 />59 <br />MAJOR MINOR <br />❑ <br />NO ❑— <br />VIOL. VIOL.❑ <br />VOL. <br />OFFICE: <br />INSYJ <br />RTED.BY: <br />TITLE: <br />PHONE: <br />BECK: <br />HUT -3 White - Original Yellow - Owner's Copy Pink - File Coov 5/88 0 nn <br />