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�lwl vN 1 IIVIl 1[C1'ViSI �� -$AN JOAQUIN HEALTH DISTRICT rAw 1601 E. HAZELTON AVE. COUNTY NAME 2 �C PHONE NO- 46883423 COUNTY # 3 SITE NAME: UlCG( INSPECTION DATE: �7 SITE ADDRESS: � ) f� +� � CITY/STATE/ZIP CHANGES SITE/OWNER/PERMIT? YES NO TANK Q TANK Q -L— TANK TANK FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER TY//P1E OF INSPECTION Q SITE COMPUTER # NUMBER NUMBER NUMBER NUMBER I PER rt PER# PER# PER# EXP DATE EXP DATE EXP DATE EXP.DATE OPERATIONAL TANK TANK CONTENTS MRJOR MINOR PERMIT TO OPERATE 1 2 — CHANGE IN CONDITIONS TO OPERATE 3 4 --------- --�------- ,'I APPROVED CONSTRUCTION 5 6 — — ------ WRITTEN MONITORING PROCEDURES 7 8 APPROVED MONITORING SYSTEM 9 10 — — MONITORING SYSTEM 11 12 APPROVED MONITOR FREOUENCY 13 14 _ — -- I MONITORING RECORDS MAINTAINED 15 16 I ACCESS CASING SECURED 17 18 ----- -- — ---- f PIPING i9 20 INVENTORY RECONCILIATION 21 22 — — �— TANK GAUGING 23 24 _ ---- —— — APPROVED RESPONSE PLAN 25 26 UNAUTHORIZED RELEASE OCCURRENCE 27 28 SAMPLING 29 30 F APPROVED TANK REPAIRS 31 32 — _ UNAUTHORIZED RELEASES REPORTED 33 34 SAFETY HAZARD 35 36 CONDITIONS ABATED TEMPORARY TANK CLOSURE ' � s4" �'• ` _ - ; •+3d t �.5 ani€ IV"'sr t REMOVAL OF RESIDUAL 38 39 FLAMMABLE VAPORS REMOVED 40 ACCESS LOCATIONS SEALED 41 42 POWER DISCONNECTED 43 OWNER/OPERATOR MONITORING 44 45 i 1 PERMANENT TANK CLOSURE REMOVAL OF RESIDUAL MATERIALS 46 147 , _,. PIPING 48 49 ..._ FLAMMABLE VAPORS REMOVED 50 UNAUTHORIZED RELEASE 51 152SAMPLING 53 IMPROPER ABANDONMENT 55 56 THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE COR TED AS SYSTEM STATUS(MUST MARK ONE) FOLLOWS: Q _ or MAJOR 57 MINOR 58 59 NO VIOL. L] MINOR VIOL.❑ — a OFFICE: INSP� ECEIVED BY: TITLE: n _ PHONE: RECK: 41 IT»—q 0