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4 v MIGNOU►Ip TANK OFFICIAL INSPECTION ORT <br /> MNMAC� MflMNMETLHETH DIVISION <br /> 445 N.San Joaquin Street <br /> Maillnq Atloress: P.O.Box 388 <br /> COMITY NAME StoUaon•CA 95201-0388 <br /> 458.3420 COUNTY # <br /> SITE NAME: INSPECTION DATE: <br /> SITE ADDRESS; E ?o CITY/STATE/ZIP G06r <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK JaL TANK rx'j TANK /qL TANK BG <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> TYPE OF INSPECTION SITE COMPUTER I NUMBER NUMBER INUMBER INUMBER <br /> PER s PER .r PER# PER a <br /> 1ej5;;df0 EXP.DATE DATE EXP.DATE EXP 'J iE <br /> OPERATIONAL TANK <br /> MAJOR MINOR <br /> PERMIT TO OPERATE 1 2 <br /> EEEM- <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 -- - <br /> APPROVED CONSTRUCTION 5 6 <br /> WRITTEN MONITORING PROCEDURES 7 8 --- ---_---------- .._ _. . __ ._ _ <br /> APPROVED MONITORING SYSTEM 9 10 <br /> MONITORING SYSTEM 11 12 -------------- <br /> APPROVED MONITOR FREQUENCY 13 114 <br /> MONITORING RECORDS MAINTAINED 15 16 ---`— <br /> ACCESS CASING SECURED 17 18 ------"- - `- -- <br /> PIPING 19 <br /> INVENTORY RECONCILIATION 21 <br /> TANK GAUGING - 23 24 - - - - <br /> APPROVED RESPONSE PLAN 25 26 <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 28 -'------I <br /> SAMPUNG 29 30 <br /> APPROVED TANK REPAIRS 31 132 1 --'-- <br /> UNAUTHORIZED RELEASES REPORTED 33 134 <br /> SAFETY HAZARD <br /> 35 38 <br /> • CONDITIONS ABATED 37 <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL 38 39 <br /> FLAMMABLE VAPORS REMOVED 40 <br /> ACCESS LOCATIONS SEALED 41 42 <br /> POWER DISCONNECTED M 43 <br /> OWNER/OPERATOR MONITORING 44 45 - <br /> PERMANENT TANK CLOS I!--�, .` <br /> REMOVAL OF RESIDUAL MAT I 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: 5; zc <br /> 57 58 59 <br /> VIOL. R ❑ VIOOR ❑ VOL❑ <br /> OFFICE: INSP: RECEIVED BY: <br /> TITLE: PHONE: RECK: <br /> HUT-3 White-Onginal Yellow-Owners Copy Pink-File Copy siea O M <br />