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UNDERGROU TANK PROGRAM OFFICIAL INSP TION REPORT AN JOAQUIN HEALTH DISTRICT 1601 E. HAZELTON AVE. STOCKTON, CA 95205 COUNTY # COUNTY NAME PHONE NO. 468-3423 SITE NAME: INSPECTION DATE: 9 &A wes/ /'l(,oC� SITE ADDRESS: 1166 D„l CITY/STATE/ZIP / TAN TANK NK CHANGES SITE/ TANK YES// NO COMPUTER TANK COMPUTER COMPUTERANKS COMPUTER FORM A AND/OR B SUBMITTED? NUMBER NUMBER NUMBER NUMBER TYPE OF INSPECTION SITE COMPUTER# PER# PER # PER # PER# P z �� EXP.DATE EXP DATE EXP.DATE EXP.DATE TANK CONTENTS OPERATIONAL TA MAJOR MINOR PERMIT TO OPERATE 1 2 __ - - --"--- ---_--"`"— CHANGE IN CONDITIONS TO OPERATE 3 4 APPROVED CONSTRUCTION 5 6 -- -- — - WRITTEN MONITORING PROCEDURES 7 8 -- -- --" - APPROVED MONITORING SYSTEM 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 39 FLAMMABLE VAPORS REMOVED 40 - ACCESS LOCATIONS SEALED 41 42 - -, POWER DISCONNECTED 43 -" -- OWNER/OPERATOR MONITORING44 45 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 MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS SYSTEM STATUS(MUST MARK ONE) FOLLOWS: 57 58 59 MAJNO VIOLOR ElVIOLO.R ❑ VIOL❑ OFFICE INSP: RECEIVED BY: All TIT V. PHONE: RECK: siea O� HUT-3 ORIGINAL