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UNDERGROU I TANK PROGRAM OFFICIAL INS( <br />*, SAN JOAQUIN HEALTH DISTRICT <br />1601 E. HAZELTON AVE. <br />STOCKTON, CA 95205 <br />COUNTY NAME PHONF NO 468-3423 <br />;TION REPORT <br />COUNTY # <br />SITE NAME: se � <br />S <br />INSPECTION DAT <br />E <br />SITE ADDRESS:aZ <br />CITY/STATE/ZIP <br />CHANGES SITE/OWNER/PER <br />? YES <br />NO <br />TANK &I <br />TANK Q a— <br />TANK 6 3 TANK l�O <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />NUMBER <br />COMPUTER <br />NUMBER <br />COMPUTER COMPUTER <br />NUMBER NUMBER <br />TYPE OF INSPECTION SffE COMPUTER # <br />PER # <br />PER # <br />PER # PER # <br />S r_ <br />'45� <br />EXP. DATE- <br />EXP. DATE <br />EXP. DATE EXP. DATE <br />OPERATIONAL TAN <br />TANK <br />CONTENTS <br />MAJOR I 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 />APPROVED MONITORING SYSTEM <br />9 <br />MONITORING SYSTEM <br />11 <br />APPROVED MONITOR FREQUENCY <br />13 <br />q14 <br />MONITORING RECORDS MAINTAINED <br />15 <br />ACCESS CASING SECURED <br />17 <br />PIPING <br />19 <br />20 <br />INVENTORY RECONCILIATION <br />21 <br />22 <br />TANK GAUGING <br />23 <br />24 <br />_ <br />APPROVED RESPONSE PLAN <br />25 <br />26 <br />____ <br />UNAUTHORIZED RELEASE OCCURRENCE 27 <br />28 <br />_ ____ <br />SAMPLING <br />29 <br />30 <br />____ _ <br />------- <br />_ <br />APPROVED TANK REPAIRS <br />31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED 33 <br />UNAUTHORIZED <br />34 <br />_ <br />SAFETY HAZARD <br />35 <br />36 <br />_____ <br />_ <br />CONDITIONS ABATED <br />37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />FLAMMABLE VAPORS REMOVED <br />777 <br />ACCESS LOCATIONS SEALED <br />&44 <br />t451 <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 />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)FOLLOWS: <br />57 58 <br />59 <br />- <br />❑ <br />NO <br />❑ <br />VIOL LlVIOLOR <br />VIOL <br />OFFICE: <br />I <br />n <br />RECEIVED BY:SQ,n <br />y <br />w <br />TITLE I "f' C(jyV <br />PHONE: <br />BECK: <br />HUT -3 ORIGINAL Sias 0 <br />