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UNfkGROUND TANK OFFICIAL INSPECTION REIT T <br /> SAN JOAOUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.Weber Ave.,Third Floor <br /> Mailing Address:P.O.Box 388 <br /> COUNTY NAME Sloo4on,CA95201-0388 COUNTY # <br /> ase-3420 <br /> SITE NAME: /�/) � INSPECTION DATE��,4k -y— <br /> � <br /> SITE ADDRESS: /J CITY/STATE/ZIP <br /> � <br /> 11 ' P,30, 40A I4 <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK TAN< 'TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> NUMBER NUMBER NUMBER NUMBER <br /> TYPE OF INSPECTION 71TE COMPUTER PER * PER# PER a PER # <br /> EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK TAN1c CONTENTS [ T <br /> MAJOR M06 i <br /> PERMIT TO OPERATE 1 2 <br /> CHANGE 1N CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 6 <br /> WRITTEN MONITORING PROCEDURES 7 S <br /> APPROVED MONIIORING SYSIEM 9 10 <br /> MONITORING SYSTEM 11 12 <br /> APPROVED MONITOR FREQUENCY 13 14 <br /> MONITORING RECORDS MAINTAINED 15 IS <br /> ACCESS CASING SECURED 17 18 <br /> PIPING 19 20 <br /> :NVENTORY RECONCILIATION 21 22 <br /> . . <br /> TANK GAUGING 23 24 <br /> APPROVED RESPONSE PLAN 25 26 <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 28 <br /> SAMPLING 29 30 <br /> APPROVED TANK REPAIRS 31 32 <br /> UNAUTHORIZED RELEASES REPORTED 33 34 <br /> SAFETY;TAZARD 35 36 <br /> CONDITIONS ABATED 37 <br /> TEMPORARY TANK CLOSUREAM <br /> REMOVAL OF RESIDUAL 38 39 <br /> FLAMMABLE VAPORS REMOVED 40 <br /> ACCESS LOCATIONS SEALED 41 42 <br /> POWER DISCONNECTED 43 <br /> OWNER/OPERATOR MONITORING 44 45 <br /> , <br /> PERMANENT TANK CLOSURE `�; sAFFi� <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 /> 1TFE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONEI F"OLLOW&-15 — <br /> 57 58 59 <br /> MINOR NO <br /> VIOL.MAJOR ❑ VIOL. VOL. <br /> OFFICE: INSP: RECEIVED BY: <br /> TITLE: PHONE: BECK: <br /> HUT.-.3 While.Original Yellow-Owners Copy Pink-File Copy <br /> PHS 178 (4196) <br />