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*RGROUND TANK OFFICIAL INSPECTION AT <br /> • SAN JOAOUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.Weber Ave., hird Floor <br /> Mailing Address:P.O.Box 388 <br /> COUNTY NAME Stockton,CA 95201-0388 COUNTY # <br /> 488-3420 <br /> SITE NAME: � }� INSPECTION DATE: �,/�3✓ <br /> SITE ADDRESS: �� �� ��6`c�r�d CITY/STATE/ZIP S`�"�C v�1 gsoob <br /> CHANGES SITE YES NO TANK f TANK Z TANK 13 TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> NUMBER NUMBE NUMBER NUMBER <br /> TYPE OF INSPECTION SITE COMPUTER <br /> ?# PER# n V PER# 7�j 0 PER# Iq i®LQ PER# <br /> EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> TANK CONTENTS ` ! r y i Wxy,r�° i <br /> OPERATIONAL TANK IN <br /> MAJOR MOR .IY <br /> PERMIT TO OPERATE 1 2 <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 jet u� ©�l"� <br /> APPROVED CONSTRUCTION 5 6 \SZ _rt1k3 <br /> WRITTEN MONITORING PROCEDURES 7 8ISs\u\� <br /> APPROVED MONITORING SYSIEM 9 IU 1� �i ll�e�l p�L� ,;L&N <br /> MONITORING SYSTEM 11 12 \\ r <br /> APPROVED MONITOR FREQUENCY 13 14 <br /> MONITORING RECORDS MAINTAINED 15 16 <br /> ACCESS CASING SECURED 17 IS <br /> PIPING 19 20 r � 1 ck <br /> A) iv�uc <br /> ;NVENTORY RECONCILIATION 21 22 }�- {s t0 +ca <br /> TANK GAUGING ` 23 24 S­­A__ <br /> Qv 'C <br /> APPROVED RESPONSE PLAN 25 26 <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 28 ��� <br /> SAMPLING 29 30 <br /> APPROVED TANK REPAIF,IS 31 32 / <br /> UNAUTHORIZED RELEASES REPORTED 33 34 r-� ' L r E loo 0� <br /> SAFETY HAZARD R 35 36 <br /> CONDITIONS ABATED 37 <br /> TEMPORARY TANK CLOSURE r ' � z ;p{\ t H�tAa. <br /> ,,. <br /> REMOVAL OF RESIDUAL* 38 139 <br /> FLAMMABLE VAPORS REMOVED 40 <br /> ACCESS LOCATIONS SEALED 41 42 <br /> POWER DISCONNECTED 43 <br /> OWNER/OPERATOR MONITORING 44 45 <br /> PERMANENT TANK CLOSURE <br /> REMOVAL OF RESIDUAL.,MATERIALS 46 47 <br /> PIPING 48 49 <br /> FLAMMABLE VAPORS REMOVED 50 <br /> UNAUTHORIZED RELEASE 51156 <br /> 2 <br /> SAMPLING 53 4 <br /> IMPROPER ABANDONMENT 55 <br /> THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUSr M RK ONE) FOLLOWS — -- -- --- - <br /> 57 58 59 <br /> VIOL R ❑ VIOL.NR ❑ No VOL.❑ _ -- — -- ------ <br /> OFFICE: INSP:,,, t, RECEI ED B�� <br /> t75�1'1 CC51�`' , <br /> I TITLE: as PHONE: BECK: <br /> CX <br /> HUT-3 While-Original Yellow.Owner's Copy Pink.File Copv <br /> PHS 178 (4/96) <br /> - J <br />