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UORGROUND TANK OFFICIAL INSPECTION Re!!C)RT <br />SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N. San Joaquin Street <br />r Mailing Address: P.O. Box 388 <br />COUNTY NAMEr JIM -- /)17 6, j/ /' sto��con,CA95201-0388 COUNTY # (% <br />HUT -3 White - Original Yellow - Owner's Copy Pink - File Copv , -, M <br />SITE NAME: �{ �� <br />, <br />`� <br />INSPECTION DATE: <br />SITE ADDRESS:9d/ <br />CITY/STATE/ZIP <br />S/ C111 <br />CHANGES SITE/OWNER/PERMIT? <br />YES <br />NO <br />TANK <br />TANK <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />NUMBER <br />COMPUTER <br />NUMBER <br />COMPUTER <br />NUMBER <br />COMPUTER <br />NUMBER <br />TYPE OF INSPECTION <br />SITE COMPUTER # <br />r.2 <br />3 <br />;t1 <br />/ <br />PER # <br />PER # <br />PER # <br />PER # <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERA A <br />TANK CONTENTSk�? <br />MAJOR MINOR <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 />✓ <br />; <br />INVENTORY RECONCILIATION <br />21 <br />22 <br />TANK GAUGING <br />23 <br />24 <br />____ <br />_._..... ....... .... ... ..... .__ _ <br />APPROVED RESPONSE PLAN <br />25 <br />26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />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 />43 <br />Post -it® Fax Note 7671 <br />Date/ / al agges� <br />OWNER/OPERATOR MONITORING <br />44 <br />45 <br />l <br />To <br />From <br />PERMANENT TANK CLOSURE <br />Co./Dept. <br />Co. ITE- <br />REMOVAL OF RESIDUAL MATERIALS <br />46 147 <br />-Phone # ,� �} '?_ ✓�; C ; <br />Phone <br />PIPING <br />48 <br />49 <br />Fax # <br />Fax # D 3 <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 />56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND t UST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS: <br />61 <br />MAJOR 57 58 <br />MINOR NO <br />VIOL. �' ❑ <br />59 <br />❑ <br />i <br />L 'C -L L1i �� <br />VIOL. VIOL. <br />(- <br />OFFICE: <br />INSP: <br />r <br />R110EIVED BY: <br />� 1 <br />TITLE: <br />PHONE: <br />BECK: <br />HUT -3 White - Original Yellow - Owner's Copy Pink - File Copv , -, M <br />