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UNDERGROUND TANK PROGRAM OFFICIAL INSPECI'LON REPORT <br /> COUNTY NAME <br /> C SITE NAME --;-- INSP DATE: <br /> / I/ � `�Jl ,I Zj # CNVIROMEI TAI_ HEALTH <br /> ; �,160 �--,n1-- SEhVICES <br /> SITE ADDRESS .7 <br /> CHANGES SITE/OWNER/OPER 7 TANK TANK TANK TANK <br /> YES NO M.F.R. SUBMIT. ID M 7 ID M ID M ID I I b <br /> SITE _1* 7PTE OF INSP PER I PER M PER N PER M <br /> v1 S ,� �` EXP DATE EXP DATE EXP DATE EXP DATE <br /> OPERATIONAL VIOGATIOfIS <br /> 1. Permit to Operate <br /> 2. Change in Cond. to Operate <br /> 3. Approved Construction <br /> a. Vr ittpn ier.,.nitC inz P ..c_e.'ur:_= <br /> S. Approved Monitoring System <br /> 6. Monitoring Syst" Operational <br /> 7. Approved Monitoring Frequency <br /> 8. Monitoring Records Maintained <br /> 9. Access Casing Securd <br /> 10. Piping <br /> 11. Inventory Reconciliation v f <br /> 12. Tank Guaging <br /> 13. Approved Response Plan <br /> 14. Unauthorized Release Occurrence <br /> 15. Sampling <br /> ( 16. Approved Tank Repairs <br /> 17. Unauthorized Releases Reported <br /> 18 Safety Hazard <br /> 19. Conditions Abated <br /> TEPIPORARY CIA URE <br /> 20. Removal of Residual Materials 111/111 7777777=77 117 7 17 7-77 77 T= <br /> 21. Flammable Vapors Remvd <br /> 22. Access Locations Seale <br /> 23. Power Disconnected <br /> 24. Owner/Operator Monitoring <br /> PLIWANE21T CLOSURE <br /> 25. Removal of Residual Materials <br /> 26. Piping <br /> 27. Flammable Vapors Removed <br /> 28. Unauthorized Release <br /> 29 Sampling <br /> 30. Improper Abandonment <br /> The marked items represent violations and gust be corrected as follows: <br /> OFFICE: INSP: n RECEIVED <br /> I'i TITLE.- <br />