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{ UNDERGROUI&TANK PROGRAM OFFICIAL INSPTt©N REPORT AN JOAQUIN HEALTH DISTRICT 1601 E. HAZELTON AVE. COUNTY NAME P ONE OO. 4689342OCKTN, CA 03 COUNTY # SITE NAME: _ f INSPECTION DATE: r SITE ADDRESS: CITY'/STATE/ZIP 7�f tet,/• Gl.� «n CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK TANK TANK FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER NUMBER NUMBER NUMBER NUMBER TYPEOFINSPECTION SITE COMPUTER# PER# `# ( PER# PER# PER# v c'Wil, p p Z-/l`fd EXP,DATE EXP.DATE EXP.DATE EXP.DATE rj- OPERATIONAL TANK TANK CONTENTS E171 PERMIT TO OPERATE fQ f.0(51 C; '-_ CHANGE IN CONDITIONS TO OPERATE f ., —._ APPROVED CONSTRUCTION - - WRITTEN MONITORING PROCEDURES APPROVED MONITORING SYSTEM ---_. MONITORING SYSTEM - -- APPROVED MONITOR FREQUENCY _ MONITORING RECORDS MAINTAINED _- ACCESS CASING SECURED - PIPING 19 1120 _ _-- - INVENTORY RECONCILIATION 21 2 TANK GAUGING ZLV 24 APPROVED RESPONSE PLAN 25 26 UNAUTHORIZED RELEASE OCCURRENCE 27 28 SAMPLING 29 30 - APPROVED TANK REPAIRS 31 32 .. UNAUTHORIZED RELEASES REPORTED 33 34 SAFETY HAZARD 35 36 CONDITIONS ABATED 37 TEMPORARY TANK CLOSURE REMOVAL OF RESIDUAL 38 39 FLAMMABLE VAPORS REMOVED 40 ACCESS LOCATIONS SEALED 41 42 POWER DISCONNECTED OWNER/OPERATOR MONITORING 44 45 PERMANENT TANK CLOSURE REMOVAL OF RESIDUAL MATERIALS 46 47 -______ PIPING 48 49 FLAMMABLE VAPORS REMOVED 50 UNAUTHORIZED RELEASE 51 52 - SAMPLING 53 54 _.. .. IMPROPER ABANDONMENT 55 56 THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS SYSTEM STATUS(MUST MARK ONE) FOLLOWS: act,e MAJOR 57 59 MINOR ❑ NO VIOL. VIOL. VIOL OFFICE: INSP: RECEIVED BY: TITLE: PHONE: , 31GJ, p BECK: G� sias C�N HUTS ORIGINAL