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INVENTORY RECONCILIATION V 1��J <br /> QUARTERLY SUMMARY REPORT FORM t W'LTH <br /> ENVIRO`;T(SRRVICES <br /> Tacilttr Rage: . <br /> Tank Sue Prc�iucz� <br /> �zaso - <br /> Patiliey Adeleear: <br /> Telephone - <br /> Person Filing <br /> R <br /> Reportport <br /> 1 hereby '.ertify under Penalty of perjury that all inventory variaticas f�*r <br /> the 4bove mentioned facility were within the allowable limits for thio. <br /> Ruarter. (No in Column 13 of the Inventory Reconciliation Sheet) <br /> loventory variations exceeded the allowable limits for this quarter. ? <br /> hereby certify under penalty of perjury that the source for the vari.ratil�r' <br /> was Dot due to so una:athorixed (leak) releise. (Yes in Column 13 of the <br /> laveotory Reconciliaeion Sheet) s <br /> List date, tank I, and amount for all variations that exceeded ttbt, <br /> allowable Limits. <br /> UNDERGROUN' ANK PROGRAM OFFICIAL INSPF? ION REPORT <br /> SAN JOAQUIN HEALTH DISTRICT <br /> 1601 E. HAZELAVE. <br /> COUNTY NAME STOCKTON, CAA 95205 <br /> PHONE NO. 468-3423 COUNTY # <br /> SITE NAME: 4 1�. 7 INSPECTION DATE: <br /> SITE ADDRESS: C3 z / ' 1 r p ��� �TY�/STATE/ZIP <br /> CHANGES SITE/OWNER/PERMIT? YES NOC /TANK TA TANK TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTER I C MPUTER COMPUTER COMPUTER <br /> TYPE OF INSPECTION SITE COMPUTER# NUMBER NUMBER NUMBER NUMBER <br /> PER# PER# PER# PER# <br /> EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK TANK CONTENTS <br /> MAJOR MINOR <br /> PERMIT TO OPERATE 1 2 <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 6 ----- <br /> WRITTEN MONITORING PROCEDURES 7 8 — --- <br /> APPROVED MONITORING SYSTEM g 10 - - <br /> MONITORING SYSTEM 11 12 77 <br /> - - <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 VZ, 37 <br /> 34 <br /> SAFETY HAZARD CONDITIONS ABATED <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL 1 139 <br /> FLAMMABLE VAPORS REMOVED W44457 <br /> ACCESS LOCATIONS SEALED POWER DISCONNECTED OWNER/OPERATOR MONITORING <br /> PERMANENT TANK CLOSURE <br /> REMOVAL OF RESIDUAL MATERIALS 46 47 <br /> PIPING 48 49 <br /> FLAMMABLE VAPORS REMOVED 50 <br /> UNAUTHORIZED RELEASE 51 52 <br /> SAMPLING 53 54 <br /> IMPROPER ABANDONMENT 55 56 <br /> THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONE) FOLLOWS: el ?' C y z— <br /> MAJOR 57 MINOR 58 NO 59 <br /> VIOL D9 VIOL ❑ VIOL.❑ <br /> OFFICE: INSP: [PH <br /> ECEIVED BY: <br /> iW <br /> /\ , <br /> TITLE:y�S ON ECK: <br /> HUT-3 ORI INa,L 5/W OM <br />