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UNDERGROUTANK PROGRAM OFFICIAL INSP ION REPORT <br />AN JOAQUIN HEALTH DISTRICT <br />1601 E. HAZELTON AVE. <br />COUNTY NAME STOCKTON, CA PHONE NO. 468 3429 COUNTY # <br />SITE NAME: � �� INSPECTION DATE:// -S--23 <br />SITE ADDRESS: Z.3 S <br />cs <br />CITY/STATE/ZIP <br />_ <br />CHANGES SITE <br />FORM A AND/OR B SUBMITTED? <br />YES <br /># <br />NO <br />TANK <br />COMPUTER �/ <br />NUMBER <br />TANK / <br />COMPUTER- <br />NUMBER <br />TANK TANK <br />COMPUTER COMPUTER <br />NUMBER - NUMBER <br />TYPE OF INSPECTION SITE COMPUTER <br />PER # <br />PER # <br />PER # PER # <br />DD <br />OPERATIONAL TANK <br />TANK <br />CONTENTS <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE EXP. DATE <br />MAJOR MINOR <br />PERMIT TO OPERATE <br />1 <br />2 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 <br />4 <br />-6— <br />APPROVED CONSTRUCTION <br />5 <br />WRITTEN MONITORING PROCEDURES <br />7 <br />8 <br />APPROVED MONITORING SYSTEM <br />g <br />10 <br />MONITORING SYSTEM <br />11 <br />12 <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 />--_- <br />PIPING <br />19 <br />20 <br />INVENTORY RECONCILIATION <br />21 <br />22 <br />-- <br />TANK GAUGING <br />23 <br />24 <br />APPROVED RESPONSE PLAN <br />25 <br />26 <br />" <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 <br />28 <br />SAMPLING <br />29 <br />30 <br />APPROVED TANK REPAIRS <br />31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 <br />SAFETY HAZARD <br />35 <br />CONDITIONS ABATED <br />W-2 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />RMANENT TANK CLOSURE J <br />REMOVAL OF RESIDUAL MATERIALS <br />PIPING <br />FLAMMABLE VAPORS REMOVED <br />UNAUTHORIZED RELEASE <br />SAMPLING <br />IMPROPER ABANDONMENT <br />39 <br />IM1111111110 <br />vz�E <br />��rffl <br />55 <br />IS I tM S IAI US (MUST MARK ONE) <br />MAJOR 57 MINOR 58 NO 59 <br />VIOL. ❑ VIOL. ❑ VIOL. <br />1101MVI <br />TITLE: <br />56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />PHONE: <br />I <br />HUT -3 ORIGINAL 5188 ©M <br />