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UNDERGROUN" <br />COUNTY NAME ��A , )nro�1I..J <br />TANK PROGRAM OFFICIAL INSPECTION <br />6AN JOAQUIN HEALTH DISTRICT <br />1601 E. HAZELTON AVE. <br />STOCKTON, CA 95205 <br />PHONE NO. 468-3423 <br />REPORT <br />COUNTY # 39 <br />SITE NAME: Q <br />INSPECTION DATE: <br />SITE ADDRES ei <br />CITY/STATE/ZIP <br />S+C)CIt-Fo1v <br />CHANGES SIT /PERMIT? YES N <br />TANK 3 <br />TANK <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />NUMBER <br />NUMBER <br />NUMBER <br />NUMBER <br />TYPE OF INSPECTION SITE COMPUTER # <br />PER # <br />PER # <br />PER # <br />PER # <br />n <br />TaL., ,, P I 1 <br />R"trkt (q <br />EXP. DATE <br />EXP DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />TANK CONTENTS <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 />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 />21 122 <br />TANK GAUGING <br />23 24 <br />APPROVED RESPONSE PLAN <br />25 26 <br />_ <br />_ <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 28 <br />SAMPLING <br />29 30 <br />_ <br />APPROVED TANK REPAIRS <br />31 32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 34 <br />_ <br />SAFETY HAZARD <br />35 36 <br />CONDITIONS ABATED <br />37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />38 39 <br />FLAMMABLE VAPORS REMOVED <br />40 <br />ACCESS LOCATIONS SEALED <br />41 42 <br />_ <br />POWER DISCONNECTED <br />43 <br />OWNER/OPERATOR MONITORING <br />44 45 <br />_ <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />46 47 <br />PIPING <br />48 49 <br />FLAMMABLE VAPORS REMOVED <br />50 ME <br />UNAUTHORIZED RELEASE <br />51 52 <br />SAMPLING <br />53 54 <br />IMPROPER ABANDONMENT <br />55 56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />L. <br />SYSTEM STATUS (MUST MARK ONE) N (//d A'#dA s <br />FOLLOrV'rd� <br />S <br />Nbft �IUM.W �PMJOVCr.I <br />N .1/[�'/n <br />57 MINOR ❑58 NO 59 <br />MAJOR <br />d.V Ly <br />C'6'SP , <br />VIOL VIOL VIOL <br />$ <br />PSc <br />OFFICE: <br />INSP: <br />�CS <br />�lu <br />RECEIVED BY: <br />6`avJlrbrJMen �u <br />PHONE: <br />RECK: <br />TITLEwea $ �sf <br />HUT -3 ORIGINAL 5/w OM <br />