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UNDERGROUN�NK PROGRAM OFFICIAL INSPEQWN REPORT N JOAQUIN HEALTH DISTRICT 1601 E. HAZELTON AVE. n �; STOCKTON, CA 95205 COUNTY # COUNTY NAME PHONE N0. 468-3423 �p SITE NAME: vv � INSPECTION DATE: Z� � c,o 1 'PITY S�(X �1Y1 s SITE ADDRESS: f La L L! S1 L✓V CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK �j TANK TANK FORM A AND/OR B SUBMITTED? COMPUTER COMP COMPUTER COMPUTER NUMBEV1 NUMBE �� NUMBER NUMBER TYPE OF INSPE TION SITE COMPUTER# PER# "'// 0 PER# ) i PER# PER# �`..� EXP.DATE / EXP.DA E !/ EXP.DATE EXP.DATE TANK ON NI5 A4 OPERATIONAL TANK MAJOR MINOR PERMIT TO OPERATE 1 2 _ CHANGE IN CONDITIONS TO OPERATE 3 4 --- APPROVED CONSTRUCTION 5 6 WRITTEN MONITORING PROCEDURES 7 8 - - APPROVEDMONITORINGSYSTEM 9 10 MONITORING SYSTEM 11 12 _---._ APPROVED MONITOR FREQUENCY 13 14 _-.....- - - MONITORING RECORDS MAINTAINED 15 16 _ --- ACCESS CASING SECURED 17 18 ----`- PIPING 19 20 INVENTORY RECONCILIATION 21 22 '- -- TANK GAUGING 23 24 APPROVED RESPONSE PLAN 25 26 UNAUTHORIZED RELEASE OCCURRENCE 27 28 SAMPLING 29 30 APPROVED TANK REPAIRS 31 32 .. .. - - -- UNAUTHORIZED RELEASES REPORTED 33 34 _. - --" --- SAFETY HAZARD 35 36 CONDITIONS ABATED 37 TEMPORARY TANK CLOSURE REMOVAL OF RESIDUAL 38 C45 -- ---- �' FLAMMABLE VAPORS REMOVED ACCESS LOCATIONS SEALED 41 POWER DISCONNECTED _.._.. -_ _ .__.___._.-OWNER/OPERATOR MONITORING 44 PERMANENT TANK CLOSURE REMOVAL OF RESIDUAL MATERIALS 46 47 -` PIPING 48 49 _--- FLAMMABLE VAPORS REMOVED 50 UNAUTHORIZED RELEASE 51 52 SAMPLING 53 54 IMPROPER ABANDONMENT 55 56 THE MARK TEMS REPRESENT VIOLATJONS ANDMO&BE CORR`E�ED AS SYSTEM STATUS(MUST MARK ONE) FOLLOW til MAJOR 57 MINOR 58 NO 59 Q 7 VIOL. VIOL. ❑ VIOL.❑ OFFICE: INSP: RECEIVED Y: C TITLE PHONE: r`) Q RECY �tl (� siae HUT-3 ORIGINAL