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h '.I <br />.4 U*GROUND TANK OFFICIAL INSPECTION RE& <br />SAN JOAOUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 E. Weber Ave., Third Floor <br />Mailing Address: P.O. Box 388 <br />COUNTY NAME Cr c sto°kt°4 8A3sn20o'-°38e COUNTY # <br />SITE NAME:`� <br />INSPECTION DATE: A <br />SITE ADDRESS:C} J? u <br />CITY/STATE/ZIP �� . <br />CHANGES SITE <br />YES <br />NO <br />TANK <br />TANK <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />COMPUTE <br />COMPUTER <br />COMPUTER <br />NUMBER <br />PER # <br />NUMBER <br />PER # <br />NUMBER <br />PER # <br />NUMBER <br />PER # <br />T P IN, F TION <br />SIiE COMPUTER # <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />TANK CONiENrs <br />< O l <br />) <br />MAJOR <br />MINOR <br />e <br />PERMIT TO OPERATE <br />1 <br />2 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 <br />4 <br />APPROVED CONSTRUCTION <br />5 <br />6 <br />WRITTEN MONITORING PROCEDURES <br />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 />APPROVED RESPONSE PLAN <br />25 <br />26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 <br />28 <br />SAMPLING <br />29 <br />30 <br />APPROVED TANK REPAIRS <br />31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 <br />34 <br />SAFETY I IAZARD <br />135 <br />136 <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 />43 <br />OWNER/OPERATOR MONITORING <br />44 <br />45 <br />PERMANENT TANK CLOSURE <br />Z <br />Y. <br />REMOVAL OF RESIDUAL MATERIALS <br />46 <br />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 CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOW <br />- <br />57 58 <br />59 <br />MAJOR [jVIOLL..R NO <br />❑ ❑ <br />VIOL.. VOL. <br />__ _ <br />OFFICE: <br />INSP: <br />� <br />RE;: BY: <br />00, <br />P O <br />E <br />BECK: <br />v <br />TIT y. ,Y� � <br />fffrrr <br />MUT-3 While -Original Yellow - Owner's Copy Pink - File Copv <br />PHS 178 (4/96) <br />