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UNDERGRO' TANK PROGRAM OFFICIAL Ifs' -TION EP �iT/� T✓✓ -.SAN JOAQUIN HEALTH DISTRI, G9� 1601 E. HAZELTON AVE. �7 / NE COUNTY NAME PHOON, CA 95205 NO. 468-3423 COUNTY # SITE NAME: INSPECTION DATE: SITE ADDRESS: CITY/STATE/ZIP CHANGES SITE/OWNER/PERMIT? YES NO TANK NK TANK FORM A AND/OR B SUBMITTED? COMPUTER TANK COMPUTER COMPUTER COMPUTER TYPE OF INSPECTION SITE COMPUTER K NUMBER NUMBER NUMBER NUMBER PER x PER k PER # PER _J2,2111221a I-11j EXP.DATE EXP.DATE EXP.DATE EXP.DATE OPERATIO AL TANK F71NTENTSPERMIT TO OPERATE 2 CHANGE IN CONDITIONS TO OPERATE qAPPROVED CONSTRUCTION 6 ----- --_.-- -- WRITTEN MONITORING PROCEDURES 7 e - -- ----- -- - - APPROVED MONITORING SYSTEM 9 10 ---___-_ -_------- - - -- ---- MONITORING SYSTEM 1 1 12 APPROVED MONITOR FREQUENCY 13 14 - ---- ----------. MONITORING RECORDS MAINTAINED 15 16 - - '--- ---- ----- _ ACCESS CASING SECURED 17 18 - - - -- -- - --- -------..___ PIPING 19 20 ----- ----- — —-------- ----- INVENTORY RECONCILIATION 21 22 TANK GAUGING 23 24 --- --'----- ------- -- -------- APPROVED RESPONSE PLAN 25 -- UNAUTHORIZED RELEASE OCCURRENCE 27 28 - - ---- ----- SAMPLING 29 30 ------ - --- ------ ----- ----- APPROVED TANK REPAIRS32 --`-'------- - 1 UNAUTHORIZED RELEASES REPORTED 33 34 �- SAFETY HAZARD 35 36 CONDITIONS ABATED - `- - -- - ------- TEMPORARY TANK CLOSURE REMOVAL OF RESIDUAL 38 39 FLAMMABLE VAPORS REMOVED - ACCESS LOCATIONS SEALED 41 42 POWER DISCONNECTED43 OWNER/OPERATOR MONITORING 44 45 -- - -- - PERMANENT TANK CLOSURE REMOVAL OF RESIDUAL MATERIALS 46 47 PIPING -... --------- ----- - 48 49 FLAMMABLE VAPORS REMOVED - 50 UNAUTHORIZED RELEASE -- --- 51 52 SAMPLING -- 54 IMPROPER ABANDONMENT - ---- - ----- 5. 56 THE MARKED ITEMS REPRESE T VIOLATIONS AND MUST BE CORREC ED AS SYSTEM STATUS(MUST MARK ONE) FOLLOWS: 57 MAJOR - MINOR 58 NO 59 I VIOL VIOL ❑ VIOL❑ OFFICE: I INSP: CEIVE Y• TITLE: O HO L: RECK: HUT-3 UHIGINAL fa /1 �'