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1. <br />UNDERGROUN NK PROGRAM OFFICIAL INSPE ON REPORT <br />WN JOAQUIN HEALTH DISTRICT <br />1601 E. HAZELTON AVE. <br />COUNTY NAME STOCKTON, GA 95205 COUNTY # <br />PHONE NO. 468-3423 <br />SITE NAME: <br />INSPECTION DATE: <br />SITE ADDRESS:%S2-3�'-� - � <br />CITY/STATEfZIP <br />SA <br />- <br />CHANGES SITE/OWNER/PERMIT? YES <br />NO <br />TANK <br />TANK <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />NUMBER <br />`t%/ <br />NUMBER <br />NUMBER <br />NUMBER <br />TYPES OF INSPECTION <br />SITE C/OMPUTE,R,)# <br />PER # /,Xd <br />PER # <br />PER # <br />PER # <br />EXP. GATE <br />EXP. DATE <br />EXP. DATF <br />FXP DATE <br />OPERATIONAL TANK TANK CONTENTS <br />MAJOR MINOR <br />.,- <br />PERMIT TO OPERATE 1 <br />2 <br />CHANGE IN CONDITIONS TO OPERATE 3 <br />4 <br />APPROVED CONSTRUCTION 5 <br />6 <br />WRITTEN MONITORING PROCEDURES 7 <br />8 <br />APPROVED MONITORING SYSTEM 9 <br />10 <br />MONITORING SYSTEM 11 <br />12 <br />APPROVED MONITOR FREQUENCY 13 <br />114 <br />MONITORING RECORDS MAINTAINED 15 <br />16 <br />ACCESS CASING SECURED 17 <br />18 <br />PIPING 19 <br />20 <br />INVENTORY RECONCILIATION 21 <br />22 <br />TANK GAUGING 23 <br />24 <br />APPROVED RESPONSE PLAN 25 <br />26 <br />UNAUTHORIZED RELEASE OCCURRENCE 27 <br />28 <br />SAMPLING 29 <br />30 <br />APPROVED TANK REPAIRS 31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED 33 <br />34 <br />SAFETY HAZARD 35 <br />36 <br />CONDITIONS ABATED <br />37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL 38 <br />39 <br />FLAMMABLE VAPORS REMOVED 40 <br />ACCESS LOCATIONS SEALED 41 <br />42 <br />POWER DISCONNECTED <br />43 <br />OWNER/OPERATO 4fdtT6R 44 <br />45 <br />PERMANENT TANK CLOSURE <br />REM OF RESIDUAL MATERIALS 46 <br />47 <br />PIPING 48 <br />49 <br />FLAMMABLE VAPORS REMOVED 50 <br />UNAUTHORIZED RELEASE 51 <br />52 <br />Y <br />SAMPLING 53 <br />54 <br />IMPROPER ABANDONMENT 55 <br />56 <br />THE MARKED ITE?M. S' REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS {MUST MARK ONE) <br />FOLLOWS:—p,��% <br />r <br />MAJOR 57 MINOR 58 59 <br />NO <br />❑ ❑ ❑ <br />V4- <br />VIOL. VIOL. VIOL. <br />tea' <br />G�f°cfc <br />ii <br />OFFICE: <br />INSP: r,1� f �z <br />RECEIVED BY: <br />TITLE: <br />le <br />PHONE: <br />REGK: <br />HUT -3 ORIGINAL 5/88 ON <br />