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UN•GROUND TANK OFFICIAL INSPECTION RE•T <br /> SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N.San Joaquin Street <br /> Mailing Address: P.O.Box 388 <br /> COUNTY NAME aiti — - stook°as 3420° t'g3e8 COUNTY # 9 <br /> SITE NAME: INSPECTION DATE: �0 / <br /> SITE ADDRESS: / C /!'INOO <br /> CITY/STATE/ZIP S <br /> CHANGES SITE/OWNER/PERMIT? YES TANK ZTANK TANK TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUT COMPUT� COMPUTER <br /> TVP OF INSPEC ION SITE COMPUTER# NUMBER I U/,nn' NUMBE�CX, NUMBER j,� NUMBER <br /> Sr0i�> EXRDATE <br /> Uu" PER # PER# PER# <br /> EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK RPERMIT TO OPERATE CHANGE IN CONDITIONS TO OPERATEAPPROVED CONSTRUCTION WRITTEN MONITORING PROCEDURESAPPROVED MONITORING SYSTEM --- ---- <br /> MONITORING SYSTEM 11 12 <br /> APPROVED MONITOR FREQUENCY 13 14 <br /> _ .. .. .. <br /> MONITORING RECORDS MAINTAINED 15 --- —.________. _ <br /> 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 -i6 <br /> — <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 28 <br /> SAMPLING <br /> APPROVED TANK REPAIRS 31 32 <br /> UNAUTHORIZED RELEASES REPORTED 33 34 <br /> SAFETY HAZARD 35 36 <br /> CONDITIONS ABATED 37 <br /> TEMPORARY TANK CLOSURE w.y„ <br /> 't=' <br /> REMOVAL OF RESIDUAL 38 39 <br /> FLAMMABLE VAPORS REMOVED 40 <br /> ACCESS LOCATIONS SEALED 41 42 <br /> POWER DISCONNECTED 43 <br /> OWNER/OPERATOR MONITORING 44 45 <br /> ERMANENT TANK CLOSURE <br /> REMOVAL 6UAL 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: <br /> 57 58 <br /> MAJOR MINOR NO 59 <br /> VIOL. El VIOL. VIOL. <br /> OFFICE: IN CEIVED BY: <br /> ,3�s y <br /> TITLE: PHONE: PECK: <br />