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UNDERGROUN' TANK PROGRAM OFFICIAL INSPEr-'nON REPORT --eAN JOAQUIN HEALTH DISTRICT ..i 1601 E. HAZELTON AVE.STOCKTON, CA G 205 COUNTY NAME PHONE NO. 468 3423 COUNTY # 3 l SITE NAME: M/9 G INSPECTION DATE: SITE ADDRESS: 1 ,3VO /iv, Ld CrrY/STATE/ZIP S7Xk7() 1 v91/�S CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK 'j/ TANK TANK FORM A AND/OR B SUBMITTED? COMPUTER �D COMPUTEF{� O COMPUTER COMPUTER NUMBER /I.G NUMBER Y" NUMBER NUMBER TYPE /INSPECTION SITE COMPUTER#// PER# R# W r PER# PER# 6 EXP.DATE EXP.DATE EXP.DATE EXP.DATE OPERATIONAL NK TANKCONit b MAJOR I MINOR PERMIT TO OPERATE 1 2 CHANGE IN CONDITIONS TO OPERATE 3 4 APPROVED CONSTRUCTION 5 6 WRITTEN MONITORING PROCEDURES 7 8 APPROVED MONITORING SYSTEM 9 10 MONITORING SYSTEM 11 12 _ APPROVED MONITOR FREQUENCY 13 14 MONITORING RECORDS MAINTAINED 15 116 1 ACCESS CASING SECURED 17 18 PIPING 19 20 INVENTORY RECONCILIATION 21 22 TANK GAUGING 23 24 _ APPROVED RESPONSE PLAN 25 26 UNAUTHORIZED RELEASE OCCURRENCE 27 28 SAMPLING 29 30 _ APPROVED TANK REPAIRS 31 32 UNAUTHORIZED RELEASES REPORTED 33 34 _ SAFETY HAZARD 35 _ CONDITIONS ABATED 37 TEMPORARY TANK CLOSURE REMOVAL OF RESIDUAL 38 39 FLAMMABLE VAPORS REMOVED 40 ACCESS LOCATIONS SEALED 41 42 POWER DISCONNECTED 43 OWNER/OPERATOR MONITORING 44 45 PERMANENT TANK CLOSURE mr, REMOVAL OF RESIDUAL MATERIALS 46 47 Ell— PIPING 48 49 FLAMMABLE VAPORS REMOVED 50 UNAUTHORIZED RELEASE 51 52 SAMPLING 53 54 IMPROPER ABANDONMENT 55 56 THE MAR ED ITEMS REPRESENT VIOLATIONS AND MUST /QBE CORRECTED AS SYSTEM STATUS(MUST MARK ONE) FOLLOWS: Ak 58 MAJOR 57 MINOR NO 59 S ✓ Z� VIOL VIOL ❑ VIOL❑ Ga. O r OFFICE: INSP: RE EI E BY: TITLE: � RECK: HUT-3 ORIGINAL 5188 ©,