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UNDERGROU TANK PROGRAM OFFICIAL INSPF- TION REPORT <br />�►.''y w-_ AN JOAQUIN HEALTH DISTRIC <br />1601 E. HAZELTON AVE. <br />STOCKTN, CA 55 <br />COUNTY NAME Gyr piz t 1 7 PHONE ONO. 46893203 COUNTY # <br />SITE NAME: ^.>� l — ,; s- <br />INSPECTION DATE: <br />2lig <br />J'i <br />SITE ADDRESS: <br />CITY/STATE/ZIP <br />_ <br />CHANGES SITE/OWNER/PERMIT r. YES <br />NO TANK' <br />TANK TANK4 TANK <br />FORM A AND/OR B SUBMITTED2 <br />COMPUTER <br />COMPUT R) CQMPUTER COMPUTER <br />NUMBER <br />NUMBERyy'}/ _(')i�t1% }NUMBER NUMBER <br />TYPE OF INSPECTI N SITE COMPUTER # <br />Q <br />PER # <br />PER # PER # PER # <br />/G_ <br />t` / ' .n ( ��R-,, j .0 <br />EXP. DATE - <br />EXP. DATE EXP. DATE EXP. DATE <br />OPERATIONAL TANK TANK W <br />'ENM <br />MAJO <br />MINOR <br />PERMIT TO OPERATE 1 <br />2 <br />CHANGE IN CONDITIONS TO OPERATE 3 <br />4 <br />APPROVED CONSTRUCTION 5 <br />6 <br />WRITTEN MONITORING PROCEDURES 7 <br />8 <br />APPROVED MONITORING SYSTEM 9 <br />10 <br />MONITORING SYSTEM 11 <br />12 <br />APPROVED MONITOR FREQUENCY 13 <br />14 <br />MONITORING RECORDS MAINTAINED 15-t y16 <br />ACCESS CASING SECURED 17 <br />18 <br />PIPING 19 <br />20 <br />INVENTORY RECONCILIATION 21 <br />22 <br />TANK GAUGING 23 <br />24 <br />APPROVED RESPONSE PLAN 25 <br />426 <br />UNAUTHORIZED RELEASE OCCURRENCE 27 <br />28'' <br />SAMPLING 29 <br />30 <br />APPROVED TANK REPAIRS `- 31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED 33 J34 <br />SAFETY HAZARD 35 <br />36 <br />CONDITIONS ABATED 37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL 38 <br />39 <br />FLAMMABLE VAPORS REMOVED 40 <br />ACCESS LOCATIONS SEALED 41 <br />42 <br />POWER DISCONNECTED <br />43 <br />OWNER/OPERATOR MONITORING 44 145 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS 46 <br />47 <br />PIPING 48 <br />49 <br />M_ <br />FLAMMABLE VAPORS REMOVED 50 <br />UNAUTHORIZED RELEASE 51 <br />52 <br />SAMPLING 53 <br />54 <br />IMPROPER ABANDONMENT 55 <br />56 <br />THE MARKED <br />ITEMS REPRESENT AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS: <br />�-VIOLATIONS <br />57 ,` 58 59 <br />MAJOR MINOR NO <br />f ❑ ❑ <br />VIOL. VIOL. VIOL. <br />OFFICE: <br />INSP <br />RECEIVED BY: <br />PHONE: <br />RECK: <br />TITLE: - <br />HUT -3 OWNER'S COPY 5;85 © M <br />