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' ARGROUND TANK OFFICIAL INSPECTION IWRT <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 <br /> Stockton, <br /> s 95201-0388 COUNTY # <br /> SITE NAME: ,-, INSPECTION DATE' <br /> SITE ADDRESS: f/ cyGl✓� CITY/STATE/ZIPVTK <br /> —z,Ld <br /> CHANGES SITE/OWNER/P/ERMIT? YES NO TANK �1 TANK eZ TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> NUMBER NUMBER NUMBER NUMBER <br /> TYPE OF INSPECTION SITE COMPUTER# PER# PER # PER# PER # <br /> I62 EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL. TANKTANKCaNTENTs <br /> MAJOR MINOR <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 10 <br /> MONITORING SYSTEM 11 12 j <br /> APPROVED MONITOR FREQUENCY 3 14 ,l <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 /> SAMPLINGr3=1 <br /> 9 30 <br /> APPROVED TANK REPAIRS 32 <br /> r zaWvQA&r-C. »7 u n.= 34 <br /> 36 <br /> a mw N c <br /> 3 39 <br /> defied Fee -- <br /> 1 42 <br /> Sueual Dehvery <br /> 45 -- <br /> Re.SdriCled <br /> Reluan Receipt shcmng -to whore and Dale Dehvereo <br /> OD <br /> u7 � <br /> Return Receipt showing to wrtom 46 47 <br /> Dale.and Address of Dehvery <br /> ir rAl Postage 48 49 <br /> osta a and Fees S <br /> 50 <br /> p Postmark or 93 DaEe 51 52 <br /> 53 54 <br /> E <br /> 0 55 56 <br /> u- THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br /> co <br /> - - FOLLOWS:57 58 59 <br /> MAJOR MINOR NO - - - <br /> VIOL. VIOL. LJ VIOL. <br /> OFFICE: INSP: L RECEIVED BY: <br /> TITLE: PHONE-_ / BECK: <br /> HL1T-3 White-Original Yellow-Owner's Copy Pink-File Copy M <br />