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UNDERGROU063TANK PROGRAM OFFICIAL INSPION REPORT <br />AN JOAQUIN HEALTH DISTRICT' <br />1601 E. HAZELTON AVE. <br />COUNTYAAMEd , r ts, ,, ' STOCK> <br />PHONE TON, CA 95205 NO. 468 3423 COUNTY # <br />.. <br />SITE NAME: <br />INSPECTION DATE: { r" <br />SITE ADDRESS: <br />CITY/STATE/ZIP <br />r t <br />t , <br />CHANGES SITE/OWNER/PERMIT? YES <br />NO <br />TANK <br />TANK <br />TANK <br />TANK <br />FORM AAND/OR B SUBMITTED?`, <br />COMPUTER <br />C <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />NUMBER <br />NUMBER <br />NUMBER <br />NUMBER <br />TYPE OF INSPECTION <br />SITE COMPUTER # <br />PER #_ <br />,_ <br />PER # <br />PER # <br />PER # <br />s <br />41 <br />EXP. DATE ' <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK TANK CONTENTS <br />REM <br />MAJOR I MINOR <br />PERMIT TO OPERATE 1 <br />2 <br />CHANGE IN CONDITIONS TO OPERATE 3 <br />4 <br />APPROVED CONSTRUCTION 5 <br />6 <br />WRITTEN MONITORING PROCEDURES 7 <br />8 <br />APPROVED MONITORING SYSTEM 9 <br />10 <br />MONITORING SYSTEM 11 <br />112 <br />APPROVED MONITOR FREQUENCY 13 <br />14 <br />MONITORING RECORDS MAINTAINED 15 <br />16 <br />ACCESS CASING SECURED 17 <br />18 <br />PIPING " 19 <br />20 <br />INVENTORY RECONCILIATION 21 <br />22 <br />TANK GAUGING 23 <br />24 <br />APPROVED RESPONSE PLAN 25 <br />26` <br />UNAUTHORIZED <br />NAUT OiRIZED EJSE OCCURRENCE 29 <br />28SAMP0 <br />APPROVEDTANKS 31 <br />32 <br />------------- <br />.„_-----APPROVED <br />UNAUTHORIZED RELEASES REPORTED 33 <br />34 <br />_W .---------- <br />.. <br />SAFETY HAZARD 35 <br />136 <br />CONDITIONS ABATED 37 <br />TEMPORARY TANK CLOSURE <br />n <br />REMOVAL OF RESIDUAL 38 <br />39 <br />FLAMMABLE VAPORS REMOVED 40 <br />ACCESS LOCATIONS SEALED 41 <br />42 <br />POWER DISCONNECTED <br />43 <br />OWNER/OPERATOR MONITORING 44 <br />45 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS 46 <br />47 <br />PIPING 48 <br />FLAMMABLE VAPORS REMOVED 50 <br />49 <br />UNAUTHORIZED RELEASE 51 <br />52 <br />SAMPLING 53 <br />54 <br />IMPROPER ABANDONMENT <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS: <br />/tet f 7 .:�� <br />f, <br />?i>rF'!..'- <br />MAJOR .x 57 MINOR 58 NO 59� <br />❑ ❑ ❑ <br />�f rJ. . ,,• �E <br />VIOL VIOL. VIOL. <br />OFFICE: INSP: <br />RECEIVED BY: <br />TITLE:,`, <br />PHONE: <br />BECK: <br />HLIT-3 <br />EILF_ COPY <br />