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s ANK PROGRAM OFFICIAL INSP IvrytS6r%+' <br /> p UNDERGRla <br /> OUf Tm JOAQUIN HEALTH DISTRICT <br /> 1601,E- HAZELTON AVE. <br /> 6 STOCKTON;CA 85205 ���� # / <br /> PHONE-NO. 468-3423 "•`+- <br /> COUNTY NAME, '' "` <br /> ' a INSPECTION DATE, <br /> SITE NAME: <br /> CITY/STATE/ZiR <br /> SITE ADDRESS: ,,�6 � TANK-� ' T K+ , <br /> t �� <br /> COMPUTER COMPUTER <br /> CHANGES 5lTE/OWNER/PERMIT? Y S N COMPUTER O! COMPUTER NUMBER NUMBER.. <br /> FORM AAND/OR B SUBMITTED? NUMBER <br /> NUMBER,� ..,: s x PER # <br /> PER'# <br /> :, SITE COMPUTER# PER# } PER# �« <br /> TYPE OF INSPECTION EXP.DATE ° DATE <br /> .. e EXP <br /> EXP.DATE <br /> EXP.DATE � <br /> - nwx co►rrfrrrs <br /> - - I <br /> OPERATIONAL TANK <br /> PERMIT TO OPERATE i 2 <br /> I: .�• .. <br /> CHANGE IN CONDITIONS TO OPERATE '.. 3 4 <br /> APPROVED CONSTRUCTION °... 5 6 �, P <br /> WRITTEN MONITORING PROCEDURES i <br /> APPROVED MONITORING SYSTEM , 9 10 <br /> MONITORING SYSTEM <br /> 11 12 <br /> APPROVED MONITOR FREOUENCY 13 ' 14 <br /> MONITORING RECORDS MAINTAINED 15 16 I... . <br /> ACCESS CASING SECURED 17 18 <br /> J PIPING i 19 20 <br /> INVENTORY RECONCILIATION •,._�.� 21 22 i f <br /> ' { f ". <br />� TANK GAUGING 23 24 <br /> APPROVED RESPONSE PLAN "`a 25 26 <br /> UNAUTHORIZED RELEASE OCCURRENCE. 27 28 <br /> SAMPLING 3 F29 30 <br />'I APPROVED TANK REPAIRS ' -'31 32 Lu 'a <br /> UNAUTHORIZED RELEASES REPORTED 33 - 34 I z j <br /> SAFETY HAZARD' } � 35 36 <br /> CONDITIONS ABATED .37' <br /> 3 xx M <br /> - «r <br /> TEMPORARY TANK CLOSUREh. t per " <br /> I <br /> REMOVAL OF RESIDUAL I t 38 39 <br /> FLAMMABLE VAPORS REMOVED <br /> ACCESS LOCATIONS SEALED 41 42 } <br /> POWER DISCONNECTED r 43 If <br /> OWNER/OPERATOR MONITORING 144 t45 j ' <br /> & ,A t <br /> PERMANENT TANK CLOSURE : <br /> REMOVAL OF RESIDUAL MATERIALS 46. 47 t e' <br /> PIPING 48 49 -- c <br /> FLAMMABLE VAPORS REMOVED <br /> UNAUTHORIZED RELEASE .,.� 1 '51 52 <br /> SAMPLING I # 1 53 54 t <br /> IMPROPER ABANDONMENT - 55, 56 ► - "" <br /> s = THE MARKED IVIS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS{MUST MARK ONE) n ' FOLLOWS:57 58 V <br /> MAJOR - MINOR NO <br /> VIOL ❑ VIOL ❑ VIOL <br /> OF <br /> OFFICE: .. INSP: RECEIVED BY:' J <br /> .. `.� ..� R R <br /> JTITLE:��i .� _ PHONE. �'��{. BECK: <br /> U7-3 ORIGINAL- <br /> � . <br />