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COUNTY NAME <br />UNDERGROUND TANK CIFFICIAL INSPECTION REPORT <br />SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION c <br />445 N. San Joaquin Street <br />Mailing Address: P.O. Box 388 <br />Stockton, CA 95201.0388 COUNTY # <br />488.3420 <br />SITE NAME: --- �.L� � INSPECTION DATE: �Z <br />SITE ADDRESS:92?0 -- CITY/STATE/ZIP <br />CHANGES SITE/OWNER/PERMIT? " YES NO <br />FORM A AND/OR B SUBMITTED? <br />TANK67Z <br />COMPUTER <br />NUMBERf'j AW4> <br />' <br />PER # Se <br />EXP. DATE <br />TANK,::::) <br />COMPUTEFk, yv�j <br />NUMBER <br />�!� <br />PER # <br />EXP. DATE <br />TANK® <br />COMPUTE <br />NUMBER <br />PER # 5rL <br />EXP. DATE <br />TANK <br />COMPUTER'' <br />NUMBER Sr®y�` <br />PER # S4111 <br />EXP. DATE <br />TYPE OF INSPECTION <br />J <br />SITE COMPUTER # <br />OPERATIONAL TANK <br />PERMIT TO OPERATE <br />CHANGE IN CONDITIONS TO OPERATE <br />APPROVED CONSTRUCTION <br />WRITTEN MONITORING PROCEDURES <br />APPROVED MONITORING SYSTEM <br />MONITORING SYSTEM <br />APPROVED MONITOR FREQUENCY <br />MONITORING RECORDS MAINTAINED <br />ACCESS CASING SECURED <br />PIPING <br />INVENTORY RECONCILIATION <br />TANK'GAUGING <br />APPROVED RESPONSE PLAN <br />UNAUTHORIZED RELEASE OCCURRENCE <br />SAMPLING <br />APPROVED TANK REPAIRS <br />UNAUTHORIZED RELEASES REPORTED <br />SAFETY HAZARD <br />CONDITIONS ABATED <br />TANK C01"NTs <br />MAJOR MINOR <br />a= <br />R <br />1 2 <br />3 4 <br />5 6 <br />7 8 <br />9 10 <br />11 12 <br />13 14 <br />1 16 <br />17 18 <br />19 20 <br />21 22 <br />23 24' <br />25 26 <br />27 28 <br />29 30 <br />31 32 <br />33 34 <br />35 36 <br />37 <br />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />PIPING <br />FLAMMABLE VAPORS REMOVED <br />UNAUTHORIZED RELEASE <br />SAMPLING <br />IMPROPER ABANDONMENT <br />3YSTEM STATUS (MUST MARK ONE) <br />�gfi <br />Im <br />W <br />®m <br />®m <br />MAJOR 57 MINA 58 NO 59 <br />VIOL. ❑ VIOL. <br />L. <br />t�.1 VIOL. ❑ <br />THE MARKED ITEMS REPRESENT <br />�VIOLATIONS SAND MUST RF C01111ECIED AS <br />FOLLOWS: <br />OFFICE: INSP:E ,G <br />�FUE'r� <br />TITLE: <br />RECEIVED BY: J <br />PHONE:TBECK: <br />