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UA.tRGROUNO TANK OFFICIAL INSPECTION Rb1.AT <br /> SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEAITTI1pIVISION <br /> 304E.Wsber Ave., hi, lw, <br /> Mailing Afteae:P.O.Boz 3W <br /> COUNTY NAME s100MOn,CA9szm-o3ee <br /> 4We20 COUNTY # <br /> SITE NAME: �_ INSPECTION DATE:/t//nrq� <br /> L <br /> SITE ADDRESS: CITY/STATE/ZIP Govt 9sEy <br /> ^� D <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK a Z TANK TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTER S� COMPUTER�� COMPUTER COMPUTER <br /> ION <br /> TYPE OF INSPECTSITE NUMBER NUMBER NUMBER <br /> E COMPUTER• /�'�Sf-C <br /> PER / PERI PER • PER <br /> / EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> MW COMENR y'i:' ! ,_'7�; r ..•: SP,n <br /> OPERATIONAL TANK idMANT miRoa - <br /> _ .., <br /> PERMIT 70 OPERATE 1 2 <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 6 <br /> WRITTEN MONITORING PROCEDURES 7 B <br /> APPROVED MONITORING SYSI EM 9 IO <br /> MONITORING SYSTEM 11 12 <br /> APPROVED MONITOR FREQUENCY 13 14 <br /> MONITORING RECORDS MAINTAINED 15 16 <br /> ACCESS CASING SECURED 17 16 <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 REPAITjS 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 e 3B 39 <br /> FLAMMABLE VAPORS REMOVED 40 <br /> ACCESS LOCATIONS SEALED 41 42 <br /> POWER DISCONNECTED 43 <br /> OWNER/OPERATOR MONITORING 44 45 <br /> PERMANENT TXNK CLOSURE r� T, 41 <br /> REMOVAL OF RESIDUAL MATERIALS [53 <br /> 47 <br /> PIPING 49 <br /> FLAMMABLE VAPORS R%MOVED <br /> UNAUTHORIZED RELEASE 52 <br /> SAMPLING 54 <br /> IMPROPER ABANDONMENT 58 <br /> THE MARKED ITEMS REPRESENT VIOLATIONS AND(JUST BE CORRECTED AS <br /> SYSTEM STATUS(Must MARK ONE) FOLLOWS: S45.5 1946;e57 6 511 59 <br /> VIOL R LJVMIN NO <br /> IOL.R ❑ VIOL❑ —._----_.—____ <br /> OFFICE: INSP: RECEIVED BY: <br /> TITLE: Q.0%41 s" PHONE: BECK: <br /> FIUT-3 Whl1e-OrIgInsl Yellow.Owner'e COPY PION-File COPV <br /> PHS 1 (4/96) <br />