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UNDERGROU TANK PROGRAM OFFICIAL INSP ^TION REPORT WSAN JOAQUIN HEALTH DISTRICTV 1601 E. HAZELTON AVE. 205 COUNTY NAME S. T P ONETNO- 468-3 423 COUNTY # SITE NAME: — �j�m�, INSPECTION DATE: h G SITE ADDRESS: T for CITY/STATE/ZIP N,5 /nG1 CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK TANK TANK FORM AAND/OR B SUBMITTED? COMPUTER/;2� R COMPUTER COMPUTER NUMBER MBER NUMBER NUMBER TYPE OF INSPECTION SITE COMPUTER# PER#A— PER# PER# PER# EXP.DATE EXP.DATE EXP.DATE EXP.DATE OPERATIONAL TANK TANK CONTENTs MAJOR MINOR l PERMIT TO OPERATE 1 2 CHANGE IN CONDITIONS TO OPERATE 3 4 APPROVED CONSTRUCTION 5 6 WRITTEN MONITORING PROCEDURES 7 8 APPROVED MONITORING SYSTEM 9 10 MONITORING SYSTEM 11 12 APPROVED MONITOR FREQUENCY 13 14 MONITORING RECORDS MAINTAINED 15 16 ACCESS CASING SECURED 17 118 PIPING 19 120 1 INVENTORY RECONCILIATION 21 22 TANK GAUGING 23 24 APPROVED RESPONSE PLAN UNAUTHORIZED RELEASE OCCURRENCE 27 28 SAMPLING 29 30 - APPROVED TANK REPAIRS UNAUTHORIZED RELEASES REPORTED 33 34 SAFETY HAZARD35 36 _ _ CONDITIONS ABATED 37 TEMPORARY TANK CLOSURE REMOVAL OF RESIDUAL V4445 FLAMMABLE VAPORS REMOVED ACCESS LOCATIONS SEALED POWER DISCONNECTED _ OWNER/OPERATOR MONITORING - 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 VIOLATIQNS AND MUST BE CORRECTED AS SYSTEM STATUS(MUST MARK ONE) FOLLOWS: S H.0 AWed- Did 57 58 59 ri S.® +Y000 a,u/ sast./cc.,� MAJOR INO OL. ❑ VIOLL..R ❑ VOL❑ OFFICE: INS P: ! pz— RECEIVED BY: TITLE: H� PHONE: RECK: 16 8-�ylO� HUT-3 ORIGINAL seas