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UNDERGROUN ANK PROGRAM OFFICIAL INSPE <br />--SAN JOAQUIN HEALTH DISTRICT <br />1601 E. HAZELTON AVE. <br />COUNTY NAME STOCKTON, CA 95205 <br />PHONE NO. 468-3423 <br />'TION REPORT <br />♦. <br />COUNTY # 39 <br />SITE NAME: � <br />INSPECTION DATE: <br />SITE ADDRESS: 103-dGt�rR <br />/G��SC�i <br />C'�GCB <br />CITY/STATE/ZIP <br />CHANGES SITE/OWNER/PERMIT? YES KID <br />FORM A AND/OR B SUBMITTED? <br />TANK <br />GOMPUTFR <br />TANK <br />COMPUTER <br />TANK <br />COMP <br />R <br />TANK <br />CQYPUT <br />NUMBE <br />PER # <br />EXP. DATE <br />NUMB,- <br />PER # 7 <br />EXP. DATE <br />NUMBER <br />PER #� <br />EXP. DAT <br />�' <br />R <br />PER <br />EXP. DATE <br />TYPE OF IN PECTION <br />s:194 -p-1 <br />SITE COMPUTER # <br />V <br />OPERATIONhL TANK TANK COR Nis <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 />_ <br />APPROVED MONITORING SYSTEM 9 10 <br />MONITORING SYSTEM 11 12 <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 />_ <br />SAMPLING 29 30 <br />APPROVED TANK REPAIRS 31 32 <br />UNAUTHORIZED RELEASES REPORTED 33 134 <br />SAFETY HAZARD 35 36 <br />CONDITIONS ABATED 37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />W4445 <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS r46 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 TEEMS REPRESENTT VIOLLAATIONS ND MUST <br />BE COR TED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />MAJOR 57 MINOR 58 NO (,j59 <br />VIOL El VIOL ❑ VIOL. WJ <br />FOLLOWS: <br />OFFICE: <br />INSP: <br />RECEIVED BY: <br />TITLE: <br />PHONE: <br />RECK: <br />HUT -3 <br />r — <br />ORIGINAL <br />5/88 C <br />