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r. <br /> UNWERGROUND TANK OFFICIAL INSPECTION %,` RT <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 HAIE �- a f - Stockton,CA 95201-0388 <br /> . *u .1 468.3420 COUNTY # <br /> SITE NAME: INSPECTION DATE: �O'a1i yj� <br /> SITE ADDRESS: a pr b S-f CITY/STATE/ZIP <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK a- TANK TANK <br /> FORM AAND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> 11E OF INSPECTION SITE COMPUTER# NUMBER NUMBER NUMBER NUMBER <br /> PER# PER# PER# PER# <br /> a 31 EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OP TANK CONTENTS <br /> MAJOR I MINOR f _ <br /> PERMIT TO OPERATE 1 2 <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 6 <br /> WRITTEN MONITORING PROCEDURES 7 8 <br /> APPROVED MONITORING SYSTEM 9 110 <br /> MONITORING SYSTEM 11 12 APPROVED MONITOR FREQUENCY13 14 _JD 6 <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 /> UNAUTHORIZED RELEASE OCCURRENCE 27 28 <br /> SAMPLING 29 30 <br /> APPROVED TANK REPAIRS 31 32 <br /> UNAUTHORIZED RELEASES REPORTED 33 34 <br /> SAFETY HAZARD 35 36 <br /> CONDITIONS ABATED 37 <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL 38 39 _ <br /> FLAMMABLE VAPORS REMOVED 40 <br /> ACCESS LOCATIONS SEALED 41 42 _ <br /> POWER DISCONNECTED 43 J — <br /> OWNER/OPERATOR MONITORING 44 45 <br /> PERMANENT TANK CLOSURE " <br /> REMOVAL OF RESIDUAL MATERIALS 46 147 <br /> PIPING 48 49 _ <br /> FLAMMABLE VAPORS REMOVED 50 <br /> UNAUTHORIZED RELEASE 51 52 <br /> SAMPLING 53 54 <br /> IMPROPER ABANDONMENT 55 56 <br /> THE R D ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONE) FOLLOWS: to Q <br /> MAJOR 57 MINOR 58 NO 59 <br /> VIOL VIOL ❑ VIOL❑ <br /> OFFICE: INSP: t RECEIVED BY: <br /> TITLE:,S F-A;16� s ONE: BECK: <br /> HUT-3 White-Original Yellow-Owners Copy Pink-File Copv 5ise 0 x <br />