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M OFFICIAL <br />UNDERGROUNAN JOAQUINAHEALTH DISTRICT „ON REPORT <br />"5 1601 E. HAZELTON AVE. <br />STOCKTON, CA 95205 Cowff # <br />VAMC .no n.nn <br />9 <br />35 <br />oum.i <br />f <br />INSPECTION DATE: / <br />SITE NAME: / <br />ntm <br />71- <br />SITE ADDRESS: -777 S� <br />�i2GONA u T CITY/STATE/ZIP ,S7Xfl, <br />CHANGES SITE/OWNER/PERMIT? <br />YES <br />NO <br />TANK TANK 7j <br />TANK TANK <br />FORM AAND/OR B SUBMITTED? <br />COMPUTER �f COMPUTERSy-V <br />NUMBER GSYY ER <br />COMPUTER COMPUTER <br />NUM BER NUMBER <br />TYPE OFFVINV`�ECT.I SITE COMPUTER N <br />/iN <br />PER # r5 PER S <br />PER <br />R O <br />EXP. DATE EXP DATE <br />EXP. DATE EXP DATE <br />OPERATIONAL TANK <br />TANK <br />R MINNOR <br />MAJOR MR <br />PERMIT TO OPERATE <br />1 <br />2 <br />_.... <br />CHANGE IN CONDITIONS TO OPERATE <br />3 <br />4 <br />_ <br />APPROVED CONSTRUCTION <br />5 <br />6 <br />WRITTEN MONITORING PROCEDURES <br />7 18 <br />APPROVED MONITORING SYSTEM <br />9 110 <br />MONITORING SYSTEM <br />11 112 <br />APPROVED MONITOR FREQUENCY <br />13 114 <br />MONITORING RECORDS MAINTAINED <br />15 116 <br />ACCESS CASING SECURED <br />17 118 <br />PIPING <br />19 120 <br />INVENTORY RECONCILIATION <br />21 <br />22 <br />' <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 />29 <br />30 <br />APPROVED TANK REPAIRS <br />31 <br />32 <br />_ <br />UNAUTHORIZED RELEASES REPORTED <br />33 <br />34 <br />SAFETY HAZARD <br />35 <br />36 <br />CONDITIONS ABATED <br />37 <br />TEMPORARY TANK CLOSURE <br />{ ' <br />REMOVAL OF RESIDUAL <br />3B <br />39 <br />_ <br />FLAMMABLE VAPORS REMOVED <br />40 <br />ACCESS LOCATIONS SEALED <br />41 <br />42 <br />POWER DISCONNECTED <br />43 <br />OWNER/OPERATOR MONITORING <br />44 <br />45 <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 (MUST MARK ONE) <br />lrS <br />FOLLOWS:58 <br />57 <br />59vi <br />MAJOR MINOR NO <br />❑ ❑ <br />I <br />VIOL. VIOL. VIOL <br />jInil <br />OFFICE: <br />RECEIVED BY: <br />INITSP: <br />E: r6 /l/ <br />PHONE: <br />RECK: <br />HUT -3 ORIGINAL <br />