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UNDERGROUF TANK PROGRAM OFFICIAL INSP TION REPORT AN JOAQUIN HEALTH DISTRICT 1601 E. HAZELTON AVE. COUNTY NAME STOCKON, CA 95205 PHONE TNO. 468-3423 COUNTY # SITE NAME: INSPECTION DATE: SITE ADDRESS: SSS /• CITY/STATE/ZIP / cif,j �+97�cS CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK TANK TANK FORM A AND/OR B SUBMITTED? COMPUTER �� COMPUTER COMPUTER COMPUTER TYPE OF INSPECTION SITE COMPUTER# NUMBER NUMBER NUMBER NUMBER /�� PER# PER# PER # PER# �� EXP.DATE EXP.DATE EXP.DATE EXP.DATE OPERATIONAL TANK TANK CONTENTS MAJOR MINOR �i 7 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 SYSTEM11 12 - --_""----""- -- APPROVED MONITOR FREQUENCY 13 14 -- "" -- MONITORING RECORDS MAINTAINED 15 16 ACCESS CASING SECURED 17 18 -- -- -- - -- PIPING 19 INVENTORY RECONCILIATION 21 22 -- -- `-- -- - - TANK GAUGING 23 24 - - "-- `- - APPROVED RESPONSE PLAN 25 26 UNAUTHORIZED RELEASE OCCURRENCE 27 28 - - -- SAMPLING 29 APPROVED TANK REPAIRS 31 32 UNAUTHORIZED RELEASES REPORTED 33 34 - - -'- - SAFETY HAZARD ---'- - - 35 CONDITIONS ABATED TEMPORARY TANK CLOSURE REMOVAL OF RESIDUAL W44435 FLAMMABLE VAPORS REMOVED ACCESS LOCATIONS SEALED POWER DISCONNECTED OWNER/OPERATOR MONITORING PERMANENT TANK CLOSURE REMOVAL OF RESIDUAL MATERIALS 46 47 PIPING qg 49 FLAMMABLE VAPORS REMOVED - UNAUTHORIZED RELEASE 51 52 SAMPLING - -"-- - 53 IMPROPER ABANDONMENT 55 56 THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS SYSTEM STATUS(MUST MARK ONE) �. O MAJOR 57 MINOR 58 FOLLOWS:NO 59 VIOL ❑ VIOL. ❑ VIOL Y 4N : OFFICE: INSPBYi RECK: HUT-3 ORIGINAL 5/SB ©