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`• UNDERGROUIIPTANK PROGRAM OFFICIAL INSP,TION REPORT <br /> SAN JOAQUIN HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE. <br /> 3 <br /> COUNTY NAME STOCKTON, CA 95205 COUNTY # <br /> Serer (Z PHIO—N7E�NO. 4'68-3423 <br /> SITE NAME: Ci%%Z't�`� INSPECTION DATE: <br /> SITE ADDRESS: CITY/STATE/ZIP,3 j)(p? Ceg <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK p / TANK Q�- TANK U 3T <br /> K Q of <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTERPUTERNUMBER NUMBER NUMBERBER <br /> TYPE OF INS�P"EC�TION SITE COMP JTEERJ# PER # PER # PER# ##u) t�e / D / EXP.DATE EXP.DATE EXP.DATEDATE <br /> ..,.... . ....; .. <br /> OPERATIONAL TANK TANK CONTENTS <br /> MAJOR MINOR <br /> PERMIT TO OPERATE 1 1 12 <br /> CHANGE IN CONDITIONS TO OPERATE 13 14 <br /> APPROVED CONSTRUCTION 15 16 <br /> WRITTEN MONITORING PROCEDURES 7 es _ <br /> APPROVED MONITORING SYSTEM 9 10 <br /> MONITORING SYSTEM 11 12 <br /> APPROVED MONITOR FREQUENCY 13 14 <br /> MONITORING RECORDS MAINTAINED 15 16 <br /> ACCESS CASING SECURED 17 18 <br /> PIPING 19 20 <br /> INVENTORY RECONCILIATION 21 22 <br /> TANK GAUGING 23 24 <br /> APPROVED RESPONSE PLAN 25 26 <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 28 <br /> SAMPLING 29 30 <br /> APPROVED TANK REPAIRS 31 32 <br /> UNAUTHORIZED RELEASES REPORTED 33 34 — <br /> SAFETY HAZARD 35 36 -- <br /> CONDITIONS ABATED 37 <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL R4142 <br /> ----- <br /> FLAMMABLE VAPORS REMOVED -- <br /> ACCESS LOCATIONS SEALED POWERDISCONNECTED OWNER/OPERATOR MONITORING <br /> PERMANENT TANK CLOSURE <br /> REMOVAL OF RESIDUAL MATERIALS t55 <br /> 47 - <br /> PIPING 49 - <br /> FLAMMABLE VAPORS REMOVED <br /> UNAUTHORIZED RELEASE 52 <br /> SAMPLING ` ------ <br /> IMPROPER ABANDONMENT 56 r ✓ <br /> THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONE) FOLLOWS: <br /> MAJOR 57 MINOR 58 NO 59 <br /> VIOL. VIOL ❑ VIOL❑ <br /> r <br /> OFFICE: INSP:�y PPjYd <br /> _Z5 <br /> TITLE:�CPS <br /> ORIGINAL <br />