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UNp,,.1GROUND TANK OFFICIAL INSPECTION REF,_.Of <br />• SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENT�IL HEAITTU DIVISION <br />304 E. eber Ave., Nr Floor <br />Mailing Address: P.O. Boz 388 <br />1 <br />COUNTY NAME Sa.►v.�62 Stmkto.CA <br />34201.0368 COUNTY #3 <br />SITE NAME: S -,� <br />INSPECTION DATE: 8- <br />SITE ADDRESS: 13 Q N. <br />W7` l gpyj !,(� <br />CITY/STATE/ZIP <br />S-7,0c✓l vent C19 I <br />CHANGES SITE/OWNER/PERMIT? <br />YES NO <br />TANK <br />TANK � <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPO ER <br />NUMBER <br />PER 4 <br />COMPUTER <br />NUMBER <br />PER s <br />COMPUTER <br />NUMBER <br />PER a <br />COMPUTER <br />NUMBER <br />PER e <br />TYPE O„FfINSPECTION SITE COMPO R f <br />��•" �� d l'S D <br />EXP.DATE <br />EXP. DATE <br />EXP.DATE <br />EXP. DATE <br />OPE A NAL TANK <br />1ARK COMENl9 <br />IiIITJOR WHOR <br />PERMIT TO OPERATE <br />1 2 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 4 <br />APPROVED CONSTRUCTION <br />5 6 <br />WRITTEN MONITORING PROCEDURES <br />7 B <br />APPROVED MONI TOTTING SYSI EM <br />9 10 <br />MONITORING SYSTEM <br />11 12 <br />APPROVED MONITOR FREQUENCY <br />13 14 <br />MONITORING RECORDS MAINTAINED <br />15 16 <br />ACCESS CASING SECURED <br />17 18 <br />PIPING <br />19 20 <br />INVENTORY RECONCILIATION <br />21 22 <br />TANK GAUGING <br />23 24 <br />' <br />APPROVED RESPONSE PLAN <br />25 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 28 <br />SAMPLING <br />29 30 <br />. <br />APPROVED TANK REPAIRS <br />31 32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 34 <br />SAFETY HAZARD • <br />35 136 <br />CONDITIONS ABATED <br />37 <br />_ <br />• <br />TEMPORARY TANK CLOSURE <br />.�yaap4 <br />REMOVAL OF RESIDUAL' <br />35 39 <br />FLAMMABLE VAPORS REMOVED <br />40 <br />ACCESS LOCATIONS SEALED <br />41 42 <br />POWER DISCONNECTED <br />43 <br />OWNER/OPERATOR MONITORING <br />44 45 <br />PERMANENT TANK CLOSURE <br />yy <br />��,,a <br />REMOVAL OF RESIDUAL MATERIALS <br />46 47 <br />PIPING <br />48 49 <br />FLAMMABLE VAPORS REMOVED <br />50 1.1/ <br />/ <br />V <br />UNAUTHORIZED RELEASE <br />51 52 <br />SAMPLING <br />53 54 <br />IMPROPER ABANDONMENT <br />55 58 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLL SXNS <br />67 58 59 <br />MOTOR ❑ VIOL. NO <br />❑ VIOL. ❑ <br />_ <br />OFFICE: <br />INS���� lQ�s <br />RECEIVED BY: <br />TITLE: Sp, -K, <br />PHONE: <br />BECK: <br />HUT -3 While - Original Yellow - Owner's COPY Pink - File COPY <br />PHS 178 (4/96) <br />W <br />