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UNDERGROUNf—ANK PROGRAM OFFICIAL INSPE(- 'QN REPORT <br /> 4wAN JOAQUIN HEALTH DISTRICT ,/ <br /> 1601 E. HAZELTON AVE. <br /> CA 5205COUNTY NAME PHONETNO. 4 893423 COUNTY #& <br /> SITE NAME: # INSPECTION DATE: /p/,p& <br /> SITE ADDRESS: TCITY/STATE/ZIP <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK / TANK TANK\ TAN <br /> FORM A AND/OR B SUBMITTED? COMPUTER Co LITER COMPILER COMP ER <br /> NUMBER NUMB NUMBER\ NUMBE <br /> TY E OF INSPECTION SITE COMPUTER# PER# PER# PER# PER# <br /> d�Q EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK LINK CONTENTS <br /> MIWOR 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 <br /> APPROVED MONITOR FREQUENCY 13 14 <br /> MONITORING RECORDS MAINTAINED 15 16 <br /> ACCESS CASING SECURED 17 18 <br /> PIPING 19 120 1 <br /> INVENTORY RECONCILIATION 21 122 <br /> TANK GAUGING 23 124 1 <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 38r45 <br /> FLAMMABLE VAPORS REMOVED 40 <br /> ACCESS LOCATIONS SEALED 41 <br /> POWER DISCONNECTED <br /> OWNER/OPERATOR MONITORING 44 <br /> PERMANENT TANK CLOSURE <br /> REMOVAL OF RESIDUAL MATERIALS 46 47 <br /> PIPING 48 49 <br /> FLAMMABLE VAPORS REMOVED 50 <br /> UNAUTHORIZED RELEASE 51 52 <br /> SAMPLING 53 54 <br /> IMPROPER ABANDONMENTTHE MARKED ITEMS REPR ENT VIOLATIONS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONE) FOLLOWS: <br /> 57 58 <br /> MAJOR MINOR NO <br /> VIOL ❑ VIOL ❑ VIO' <br /> OFFICE: INSP: o q / RECEIVED BY: <br /> TITLE: PCHS PHONE: RECK: <br /> HUT-3 ORIGINAL 5/e O <br />