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�uERGROUND TANK OFFICIAL INSPECTIOORT <br /> SAN JOAQUIN PUBLIC HEALTH SERVICE* <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N.San Joeguin Street <br /> Mailing Address- P.O.Boz 388 <br /> COUNTY NAME ,Sa,YU Gam, StocMon,CA 342001.0388 COUNTY #� <br /> �(��/i a88-3420 <br /> SITE NAME: � T �1 S�R V�I C INSPECTION DATE: <br /> SITE ADDRESS: 0 7S r, I " Sfr CITY/STATE/ZIP <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK TANKS TANK TANK <br /> FORM A AND/OR B SUBMITTED? COMP ER COMPUTER COMPUTER COMPUTER <br /> NUMBER NUMBER NUMBER NUMBER <br /> TYPE OF INSPECTION 44 _ SITE COMPUTER# PE <br /> # PER # PER # PER # <br /> + j 6 (s / EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPER TIONAL -IANIC'21"- —K CONW.1 a-- O O <br /> MAJOR MINOR <br /> PERMIT TO OPERATE 1 2 <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 6 <br /> WRITTEN MONITORING PROCEDURES 7 8 <br /> APPROVED MONITORING SYSTEM 9 110 <br /> MONITORING SYSTEM 11 12 _-_. -- <br /> APPROVED MONITOR FREQUENCY 13 14 <br /> MONITORING RECORDS MAINTAINED 15 16 — -'g� _(!7 <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 26 <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 28 <br /> SAMPLING 29 130 1 - - <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 <br /> REMOVAL OF RESIDUAL 38 39 <br /> FLAMMABLE VAPORS REMOVED <br /> ACCESS LOCATIONS SEALED 41 42 _ <br /> POWER DISCONNECTED 43 <br /> OWNER/OPERATOR MONITORING 44 45 <br /> PERMANENT TANK CLOSURE <br /> REMOVAL OF RESIDUAL 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: z4c, ig 0- }� <br /> 57 <br /> 58 59 <br /> VIOL R ❑ VIOL ❑ VOL❑ <br /> OFFICE: IN /,� tcl-J RECEIVED BY: <br /> TITLE: Se7/!1 r Or RV��H J PHONE: BECK: <br /> HUT-3 White-Original Yellow-Owner's Copy Pink-File Copy siee O M <br />