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UNDERGROUND TANK PROGRAM OFFICIAL INSPECTION <br />N JOAQUIN HEALTH DISTRICT <br />1601 E. HAZELTON AVE. <br />COUNTY NAME STOCKTON, CA 96205 <br />PHONE NO. 468-3423 <br />REPORT ( l <br />��Uo'F <br />COUNTY # 5 r <br />SITE NAME: <br />INSPECTION DATE: <br />SITE ADDRESS: <br />CITY/STATE/ZIP <br />M <br />%Y3 3 4� <br />CHANGES SITE/OWNER/PERMIT? YES <br />NO <br />TANK <br />TANK <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED?- <br />COMP <br />0 0 <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />NUMB <br />NUMBER <br />NUMBER <br />NUMBER <br />TYPE OF INSPECTION <br />SITE COMPUTER # <br />PER # <br />� <br />PER # I <br />PER * <br />PER # <br />EXP DATE' <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />�NK WTEN� <br />----T—M—INOFt <br />MAJOR <br />PERMIT TO OPERATE <br />1 <br />2 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 <br />4 <br />APPROVED CONSTRUCTION <br />5 <br />6 <br />WRITTEN MONITORING PROCEDURES <br />7 <br />8 <br />APPROVED MONITORING SYSTEM <br />9 <br />10 <br />MONITORING SYSTEM <br />11 <br />12 <br />APPROVED MONITOR FREQUENCY <br />13 <br />14 <br />MONITORING RECORDS MAINTAINED <br />is <br />16 <br />ACCESS CASING SECURED <br />17 <br />18 <br />PIPING <br />19 <br />20 <br />INVENTORY RECONCILIATION <br />21 <br />122 <br />1 <br />TANK GAUGING <br />23 <br />24 <br />APPROVED RESPONSE PLAN <br />25 <br />26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 <br />28 <br />SAMPLING <br />29L <br />30 <br />APPROVED TANK REPAIRS <br />31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 <br />34 <br />SAFETY HAZARD <br />35 <br />36 <br />CONDITIONS ABATED <br />37 <br />1 <br />1 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />38 <br />3`9 <br />FLAMMABLE VAPORS REMOVED <br />40 <br />ACCESS LOCATIONS SEALED <br />41 <br />W447 <br />42 <br />POWER DISCONNECTED <br />43 <br />OWNER/OPERATOR MONITORING <br />45 <br />5 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />46 <br />47 <br />PIPING <br />48 <br />49 <br />FLAMMABLE VAPORS REMOVED <br />50 <br />UNAUTHORIZED RELEASE <br />51 <br />52 <br />SAMPLING <br />53 <br />54 <br />IMPROPER ABANDONMENT <br />55 <br />56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (mus'r MARK ONE) <br />FOLLOWS: <br />57 58 <br />59 <br />MAJOR MINOR NO <br />IVI <br />VIOL. El VIOL. El VIOL <br />VSL <br />ot <br />OFFICE: <br />Sp* <br />RECEIVED BY: <br />JIN <br />PHONE: <br />RECK <br />E: <br />"I 1r-1 ()M�TMAT <br />