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UNDERGROU TANK PROGRAM OFFICIAL INSP TION REPORT <br />SAN JOAQUIN HEALTH DISTRICIW <br />1601 E. HAZELTON AVE. <br />STOCKTON, CA 95205 COUNTY # <br />POIIAITY IJEMF - o'0-lr NO 468_3123 <br />SITE NAME: <br />INSPECTION DATE: <br />SITE ADDRESS: <br />CITY/STATE/ZIP <br />o� <br />CHANGES SITE/OWNER/PERMIT? YES NO <br />TANK <br />TANK <br />TANK 3 <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />NUMBER <br />PER # <br />COMPUTER <br />NUMBER <br />PER # <br />COMPUTER <br />NUMBER <br />PER # <br />COMPUTER <br />NUMBER <br />PER # <br />TYPE OF INSPECTION <br />SITE COMPUTER# <br />©v Xan <br />L <br />O Z <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />TANK CONTENT <br />UG <br />MAJOR MINOR <br />PERMIT TO OPERATE <br />1 2 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 4 <br />APPROVED CONSTRUCTION <br />5 6 <br />WRITTEN MONITORING PROCEDURES <br />7 8 <br />APPROVED MONITORING SYSTEM <br />9 10 <br />v <br />MONITORING SYSTEM <br />11 12 <br />APPROVED MONITOR FREQUENCY <br />13 14 <br />MONITORING RECORDS MAINTAINED <br />15 16 <br />ACCESS CASING SECURED <br />17 18 <br />PIPING <br />19 20 <br />INVENTORY RECONCILIATION <br />21 22 <br />TANK GAUGING <br />23 24 <br />APPROVED RESPONSE PLAN <br />25 26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 28 <br />SAMPLING <br />29 30 <br />APPROVED TANK REPAIRS <br />31 32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 34 <br />SAFETY HAZARD - <br />35 36 <br />CONDITIONS ABATED <br />37 <br />TEMPORARY TANK CLOSURE <br />I <br />REMOVAL OF RESIDUAL <br />38 A 39 <br />.� <br />FLAMMABLE VAPORS REMOVED <br />40 <br />ACCESS LOCATIONS SEALED <br />41 42 <br />POWER DISCONNECTED <br />_... _ <br />_.. <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 />50 <br />UNAUTHORIZED RELEASE <br />51 52 <br />SAMPLING - <br />53 54 <br />--- <br />-- <br />IMPROPER ABANDONMENT <br />55 56 <br />THE MARKED <br />ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS: <br />58 <br />59 <br />MAJOR MINOR NO <br />❑ <br />VIOL. VIOL. VIOL. <br />LJ <br />OFFICE: <br />INSP: <br />/J <br />R EI'J'D BY: <br />TITLE: <br />PHONE: <br />BECK: <br />HUT -3 ORIGINAL 'i°' <br />