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UN \ ;GROUND TANK OFFICIAL INSPECTION REI T <br /> SAN JOAOUIN PUBLIC HEALTH SERVICES *Aw <br /> ENVIRONMENT�1� A15AtgHDIVISION <br /> 304 E. <br /> Mailing Address:P.O.Boa 389 <br /> COUNTY NAME Stoclaon,CA 95201 0388 COUNTY # <br /> 488-3420 <br /> SITE NAME: INSPECTION DATE: <br /> SITE ADDRESS: CITY/STATE/ZIP <br /> CHANGES SITE YES NO TANK TANK TANK TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> NUMBER NUMBER NUMBER NUMBER <br /> OF INSPECTION SITE COMPUTER♦ PER • PER# PER A PER / <br /> EXP.DATE EXP.DATE FXP.DATE EXP.DATE <br /> OPERATIONAL TANK <br /> mA.ion I 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 IO <br /> MONITORING SYSTEM 11 12 <br /> APPROVED MONITOR FREOUENCY 13 14 <br /> MONITORING RECORDS MAINTAINED 15 16 <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 28 <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 28 <br /> SAMPLING 29 30 <br /> APPROVED TANK REPAIRS 31 32 <br /> UNAUTHORIZED RELEASES REPORTED 33 34 <br /> SAFETY I IAZARD 35 35 <br /> CONDITIONS ABATED 37 <br /> TEMPORARY TANK CLOSURET i^.a � . �l 1s,..v'Kx v �Yt" ' ti '.�"•! 1 z�.'t v,. <br /> REMOVAL OF RESIDUAL W447 <br /> 6 39 <br /> FLAMMABLE VAPORS REMOVED <br /> ACCESS LOCATIONS SEALED <br /> POWER DISCONNECTED <br /> OWNER/OPERATOR MONITORING <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 <br /> SYSTEM STATUS(MUST MARK ONE) F LOWS: -16.KdL�L- <br /> -- <br /> 57 so <br /> VIOL R VVIIIOLL..R ❑ VIIOL.� A <br /> - <br /> PE <br /> OFFICE: INSP: RECEIVE BY: <br /> TIT LE: PHONE: BECK- <br /> HUT-3 Mile Original Yellow-Own"'COnv Po,M-File COov <br /> PHS 178 (4196) <br />