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UNDERGROUND"� NK PROGRAM OFFICIAL INSPECT -NREPORT <br />`,,,,A JOAQUIN HEALTH DISTRICT <br />1601 E. HAZELTON AVE. <br />COUNTY NAME STOCKTON,CA 95205 COUNTY # 3 �% <br />PHONE NO. 468-3423 <br />SITE NAME: <br />LO1:z <br />P,ECCTION DATE&—a/�D <br />INS,/ <br />SITE ADDRESS: jO 1 d a <br />d <br />oA,�44,f <br />CITY//QST/ATE/ZIPS7LXe7� �i�r -7J �4 <br />CHANGES SITE/OWNER/PERMIT? <br />YES <br />O <br />TANKI <br />TANK y TANK TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUT <br />d' <br />COMPUTER D COMPUTER COMPUTER <br />TYPE.QF INSPEpT�ION SITE COMPUTER # <br />�7'-Ne <br />NUMBERR 0 NUMBER nU///U��' NUMBER`d � _ NUMBER <br />PER # / W I/ PER # PER # <br />-/(� PER # <br />Z 6 <br />Z6 <br />(J <br />EXP. DATE" <br />TAY <br />EXP. DATE EXP. D� EXP. DATE <br />OPERATIONAL TANK <br />TANK CONTENTS <br />MAJOR MINOR <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 />15 <br />16 <br />_ <br />ACCESS CASING SECURED <br />17 <br />18 <br />_ <br />PIPING <br />19 <br />20 <br />INVENTORY RECONCILIATION <br />21 <br />22 <br />TANK GAUGING <br />23 <br />124 <br />1_ <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 />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />W4445 <br />POWER DISCONNECTED <br />_ <br />OWNER/OPERATOR MONITORING <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 />_ <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 />FOLLOWS: <br />MAJOR 57 MINOR NO <br />❑ ❑ <br />9 <br />VIOL VIOL VIOL <br />OFFICE: <br />INSP: <br />RECEIVED B <br />TITLE: <br />_WS <br />PHONE: <br />RECK: <br />HUT -3 ORIGINAL <br />