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UN\AIGROUND TANK OFFICIAL INSPECTION RE, ,T <br /> ' SAN JOAQUIN PUBLIC HEALTH SERVICES ' <br /> ENVIRONMENTAL HEAI�T.H DIVISION <br /> 304 E.Weber Ave., erd Flom <br /> Mailing Address:P.O.Boz 388 <br /> COUNTY NAME BlocMe;g n9�1-0388 F.UUNTY # ?fJ <br /> SITE NAME: L/7� L l7 /eT.YC. �.A - ,mss INSPECTION DATE: p <br /> SITE ADDRESS: S LiTI�V CITY/STATE/ZIP <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK TANK TANK <br /> FORM A AND/OR 8 SUBMITTED? COMPUTER �JZ-0I COMPUTER COMPUTER COMPUTER <br /> NUMBER Z�jT NUMBER NUMBER NUMBER <br /> TYPE INSPECTION SITE COMPUTERyyt �7 PER# PER# PER # PER# <br /> Z✓ � EXP.DATE EXP.DATE g EXP.DATE EXP.DATE <br /> OPERATIONAL TANK mw COMENI3 iRjj t ;mvn �t t; �4/IY <br /> MIIJOH MINOR rk. h I;";%73.1, r�.; ) <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 SYS]EM 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 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 REPAIRS 31 32 <br /> UNAUTHORIZED RELEASES REPORTED 33 34 <br /> SAFETY HAZARD ♦ 35 36 <br /> CONDITIONS ABATED 37 <br /> TEMPORARY TANK CLOSURE3 � <br /> 4 Y <br /> REMOVAL OF RESIDUAL' W4445 <br /> FLAMMABLE VAPORS REMOVED <br /> ACCESS LOCATIONS SEALED <br /> POWER DISCONNECTED <br /> OWNER/OPERATOR MONITORING <br /> PERMANENT TANK CLOSURE �i1 <br /> Eli <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 ABANDONMENT 55 56 <br /> THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONE) FOLLOWS:57 58 ig <br /> - -- <br /> VIOLOR ❑ MINOR El VIOL. <br /> VIOL <br /> OFFICE: INSP: RECEIVED BY: <br /> di <br /> TITLE' PHONE: RECK: .' <br /> HUT-3 While-Original Yellow-Owner's Copy Pink-File Copy <br /> PHS 178 (4/96) <br />