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ARGROUND 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 OUNTY # <br /> E NAME: INSPECTION DATE: <br /> SITE ADDRESS: Usk CITY/STATE/ZIP ,.� t�a <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK TANK TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> TYPE OF INSPECTION SITE COMPUTER# NUMBER NUMBER NUMBER NUMBER <br /> PER# PER# UL PER# UL, PER# <br /> OL,+(Vl(-- r(L-)8Z EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK TANK CONTENTs <br /> MAJOR MINOR <br /> e <br /> PERMIT TO OPERATE 1 li2 <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 6 <br /> I/ <br /> WRITTEN MONITORING PROCEDURES 7 8 <br /> APPROVED MONITORING SYSTEM 9 10 <br /> MONITORING SYSTEM 11 12 <br /> APPROVED MONITOR FREQUENCY 13 14 <br /> MONITORING RECORDS MAINTAINED 15 16 <br /> ACCESS CASING SECURED 17 18 <br /> PIPING 19 20 <br /> INVENTORY RECONCILIATION 21 22 <br /> TANK GAUGING 23 24 <br /> APPROVED RESPONSE PLAN 25 26 <br /> _.. <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 28 l" <br /> SAMPLING P9 30 <br /> PROVED TANK REPAIRS 31 32 <br /> NAUTHORIZED RELEASES REPORTED 33 34 <br /> SAFETY HAZARD 35 36 <br /> CONDITIONS ABATED 37 <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL 38 39 s <br /> FLAMMABLE VAPORS REMOVED 40 <br /> ACCESS LOCATIONS SEALED 41 42 <br /> POWER DISCONNECTED 43 <br /> OWNER/OPERATOR MONITORING 44 45 <br /> P hG � <br /> PERMANENT TANK CLOSURE <br /> REMOVAL OF RESIDUAL MATERIALS 46 47 <br /> PIPING 48 49 <br /> FLAMMABLE VAPORS REMOVED 50 <br /> UNAUTHORIZED RELEASE 51 52 <br /> SAMPLING 53 54 <br /> IMPROPER ABANDONMENT 155 156 <br /> THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONE) FOLLOWS: <br /> 57 58 59 <br /> MAIN <br /> MAJOR MOR NO <br /> OL. VIOL. ❑ VIOL.❑ -- -- - <br /> OFFICE: INSP: � RECEIVED BY: <br /> TITLE: , PHONE: BECK: <br /> 1 HUT-3 White-Original Yel'aw-Owner's Copy Pink-File Copv N J <br />