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•NDERGROUNDTANK OFFICIAL INSPECTION19 Copy <br /> SAN IRONMN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.Weoer Ave.,Tler4 Floor <br /> iling COUNTY NAME MaSloeMon,CA 95201-6388 <br /> 459-3426 COUNTY # <br /> SITE NAME: INSPECTION DATE: S,f'�;1i7/A6 <br /> SITE ADDRESS: 'f Jr00 Gp'� f�pdS /Jvt, CITY/STATE/ZIP /9sZ5�D <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK 4 TANK S TANK s TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER/Z� COMPUTER <br /> TYPE OF INSPECITION SITE COMPUTER 0 NUMBER iZ Ln~ NUMBER /Z'"c;' NUMBER NUMBER <br /> /�OfiTiiJG 137 PER f PER / PER 4 PER e <br /> EXP DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK rnr�CONlENTS �;P t �X 5 <br /> WIAJOR W PUP <br /> PERMIT 70 OPERATE 2 <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 6 6 <br /> WRITTEN MONITORING PROCEDURES 8 <br /> APPROVED MONITORING SYSIEM g IO <br /> MONITORING SYSTEM I 1 12 <br /> APPROVED MONITOR FREQUENCY 13 14 <br /> MONITORING RECORDS MAINTAINED 15 16 <br /> ACCESS CASING SECURED 17 18 <br /> PIPING 119 120 <br /> !NVENTORY RECONCILIATION 22 <br /> TANK GAUGING <br /> 3 2 _._.__.. .... .. ..._. .._.. _P_..._. <br /> 24 <br /> APPROVED RESPONSE PLAN 25 26 <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 26 <br /> AAAA AAAA. _.. ._AAAA <br /> SAMPLING 29 30 <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 35 39 <br /> FLAMMABLE VAPORS REMOVED 40 <br /> ACCESS LOCATIONS SEALED 41 42 <br /> POWER DISCONNECTED 43 <br /> OWNER/OPERATOR MONITORING 44 45 <br /> PERMANENT TANK CLOSURE , � A � �� `$ II + <br /> } <br /> REMOVAL OF RESIDUAL MATERIALS 46 47 <br /> PIPING <br /> 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(MUSE MARK ONE) FOLLOWS: SAF TOIi(Wo1�� �fa�jL�G� <br /> t MAJOR 57 MINOR5B NO 59 <br /> l VIOL VIOL ❑ VIOL.❑ <br /> v <br /> OFFICE: =6/ REC BY:PHON . RECK: <br /> / G <br /> HUT-3 While Original yello„-Owner's Copy Pink-File Coo, -— A <br /> PHS 178 (4196) <br />