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TEMPORARY TANK CLOSURE <br />RGROUND TANK OFFICIAL 114SPEC-TIONRT <br />REMOVAL OF RESIDUAL <br />38 39 <br />SAN JOAOUIN PUBLIC HEALTH SERVICES* <br />FLAMMABLE VAPORS REMOVED <br />ENVIRONMENTAL HEALTH DIVISION <br />ACCESS LOCATIONS SEALED <br />445 N. San Joaquin Street <br />COUNTY NAME <br />POWER DISCONNECTED <br />Mailing Address: P.O. Box 388 <br />Stockton, CA 95201.0388 <br />COUNTY # <br />OWNER/OPERATOR MONITORING <br />4M-3420 <br />SITE NAME: >INSPECTION <br />PERMANENT TANK CLOSURE <br />DATE: <br />SITE ADDRESS: <br />CITY/STATE/ZIP,0:;eS;1W- 04."Y C-4— <br />CHANGES SITE/OWNER/PERMIT? <br />YES <br />No <br />TANK 10 K <br />TANK <br />TANK- --_fA­N <br />K <br />FORM AAND/OR B SUBMITTED? <br />PIPING <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />TY�EWF INSPECTION <br />SITE COMPUTER # <br />NUMBER <br />PER # <br />NUMBER <br />NUMBER <br />NUMBER <br />SAMPLING <br />53 54 <br />PER # <br />PER # <br />PER <br />IMPROPER ABANDONMENT <br />55 56 <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />TAW CONTENTS <br />FOLLOWS:-- <br />MAJOR -MINOR <br />57 58 <br />MAJOR MINOR <br />❑ Li <br />59 <br />NO tEil <br />XX <br />PERMIT TO OPERATE <br />VIOL. VIOL <br />1 <br />2 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 <br />4 <br />APPROVED CONSTRUCTION <br />INSP: ---G <br />5 <br />6 <br />c/4 L <br />WRITTEN MONITORING PROCEDURES <br />7 <br />18 <br />1 <br />PHONE( <br />APPROVED MONITORING SYSTEM <br />9 <br />10 <br />I BECK: <br />MONITORING SYSTEM <br />11 <br />12 <br />--- - <br />------ <br />APPROVED MONITOR FREQUENCY <br />13 <br />14 <br />MONITORING RECORDS MAINTAINED <br />15 <br />16 <br />ACCESS CASING SECURED <br />17 <br />18 <br />PIPING <br />19 <br />20 <br />INVENTORY RECONCILIATION <br />21 <br />22 <br />TANK GAUGING <br />23 <br />24 <br />" <br />Post-itFax Note 7671 <br />Date <br />419116 <br /># of <br />p ages <br />APPROVED RESPONSE PLAN <br />25 <br />26 <br />1 — <br />To 1Q4,5;-715Zr7" <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 <br />28 <br />Co./Dept. <br />SAMPLING <br />29 <br />130 <br />Co. <br />PAS% c—d-6 <br />APPROVED TANK REPAIRS <br />31 <br />32 <br />Phone # <br />Phone #, ey� 93 <br />(ZIA) <br />UNAUTHORIZED RELEASES REPORTED <br />33 <br />34 <br />FaxFax <br />U�j <br /># <br />SAFETY HAZARD <br />35 <br />36 <br />CONDITIONS ABATED <br />VIZ,- <br />37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />38 39 <br />FLAMMABLE VAPORS REMOVED <br />40 <br />ACCESS LOCATIONS SEALED <br />41 42 <br />POWER DISCONNECTED <br />43 <br />OWNER/OPERATOR MONITORING <br />44 45 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />46 47 <br />PIPING <br />48 49 <br />FLAMMABLE VAPORS REMOVED <br />UNAUTHORIZED RELEASE <br />- <br />51 52 <br />SAMPLING <br />53 54 <br />IMPROPER ABANDONMENT <br />55 56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS:-- <br />57 58 <br />MAJOR MINOR <br />❑ Li <br />59 <br />NO tEil <br />VIOL. VIOL <br />VIOL tN <br />OFFICE: <br />INSP: ---G <br />RECEIVED BY: <br />c/4 L <br />TITLE: <br />W-57 <br />PHONE( <br />I BECK: <br />HUT -3 White - Original Yellow - Owner's Copy Pink - File Ccpv 6i66 C'm <br />