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UNDERGROUN^ TANK PROGRAM OFFICIAL INSPF^TION REPORT <br />SAN JOAQUIN HEALTH DISTRICT <br />1601 E. HAZELTON AVE. <br />COUNTY NAME STOCKTON, CA 95205 <br />�tN cuoxrY # <br />PHONE NO. 466-3423 39 <br />SITE NAME: <br />N <br />INSPECTION DATE: <br />/;z <br />SITE <br />SITE ADDRESS: �$s6 N 13Toaduxt <br />CITY/STATE/ZIP <br />ack CA <br />CHANGES SITE/OWNER/PERMIT? <br />E O <br />TANK I <br />TANK 2 <br />TANK <br />TANK <br />FORM AAND/OR B SUBMITTED? _ <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />TYPE OF INSPECTION SITE COMPUTER # <br />NUMBER �Z QOD <br />NUMBER <br />'3'50'3'50 <br />NUMBER <br />NUMBER <br />PER # <br />PER # <br />PER # <br />PER # <br />- }- <br />K.jk '2N104Je1 15'Z7 <br />D <br />EXP. DATE <br />EXP. DATE 116,f <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />TANK CONrENTs <br />MAJOfl 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 16 <br />PIPING <br />19 20 <br />INVENTORY RECONCILIATION <br />21 22 <br />TANK GAUGING <br />23 24 <br />APPROVED RESPONSE PLAN <br />25 26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 128 <br />SAMPLING <br />APPROVED TANK REPAIRS <br />UNAUTHORIZED RELEASES REPORTED <br />A�� <br />SAFETY HAZARD <br />CONDITIONS ABATED <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />W43 <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />46 47 <br />PIPING <br />48 49 <br />--- - _ <br />FLAMMABLE VAPORS REMOVED <br />50 <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 />SYSTEM STATUS (MUST MARK ONE) <br />- <br />FOLLOWS: SeT57 <br />58 <br />59 <br />%cS , <br />MAJOR MINOR❑ NO <br />VIOL. VIOL. VIOL <br />OFFICE: <br />INSP:Cf <br />4S <br />RECEIVED BY: <br />TITLE: A eH-5 <br />PHONE: <br />RECK: <br />HUT -3 ORIGINAL 51m 0" <br />