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UNDERGROUN ANIS PROGRAM OFFICIAL INSP ON REPORT <br />WAN JOAQUIN HEALTH DISTRICT <br />COUNTY NAME 1601 E. HAZELTON AVE. <br />STOCKTON, CA 95205 <br />SITE NAME. PHONE NO. 468-3423 COUNTY # '5q <br />�� %✓i ,�- :'1 �� �i�-c �;� <br />SITE ADDREINSPECTIONDATE: <br />SS: <br />CITY/STATE/ZIP f� / �r'j f <br />CHANCES SITE/OWNER/PERMIT? YES NO TANK TANK <br />COMPUTER <br />FORM A AND/OR B SUBMITTED? TANK TANK <br />r <br />TYPE OF INSPECTION SITE COMPUTER i NUMBER,©¢ C� NUMBER/a Da NUMBER COMPUTER COMPUTER COMPUTER <br />017 /1✓ r-] ^ 5 PER # j,(! 11G If �t PER #Gf�r' PER # <br />!! T✓ EXP. DATEPER # <br />OPERATIONAL TANK ExP. GATE EXP. DATE <br />TANK CpNTEWTS, EXP. DATF <br />PERMIT TO OPERATE MAJOR MINOR <br />1 2 <br />CHANGE IN CONDITIONS TO OPERATE 3 q <br />APPROVED CONSTRUCTION 5 6 <br />WRITTEN MONITORING PROCEDURES 7 8 <br />APPROVED MONITORING SYSTEM 9 10 <br />MONITORING SYSTEM 11 12 <br />APPROVED MONITOR FREQUENCY13 14 <br />MONITORING RECORDS MAINTAINED <br />15 16 <br />ACCESS CASING SECURED 17 18 -' <br />PIPING --- - -- <br />19 20 <br />INVENTORY RECONCILIATION 21 22 ---- -- --- <br />TANK GAUGING --- <br />23 24 <br />APPROVED RESPONSE PLAN 25 26 <br />UNAUTHORIZED RELEASE OCCURRENCE 27 28 <br />SAMPLING 29 30 <br />APPROVED TANK REPAIRS -4 <br />31 32 _ <br />UNAUTHORIZED RELEASES REPORTED 33 34 <br />SAFETY HAZARD <br />35 36 <br />CONDITIONS ABATED 37 <br />-` <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />38 <br />39 <br />FLAMMABLE VAPORS REMOVED <br />40 <br />- <br />ACCESS LOCATIONS SEALED <br />41 <br />42 <br />OWER DISCONNECTED <br />r_. <br />OWNER/OPERATOR MONITORING <br />44 <br />- <br />145 <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 />UNAUTHORIZED RELEASE <br />51 <br />52 <br />SAMPLING <br />53 <br />54 <br />IMPROPER ABANDONMENT <br />55 <br />56 ---. <br />SYSTEM STATUS (MUST MARK ONE) <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />I <br />FOLLOWS:57 <br />MAJOR MINOR n <br />VIOL. LJ VIOL. <br />NO 5� <br />� 64- <br />LJ <br />VIOL. <br />zv ` <br />OFFICE: <br />INSP- ' <br />GV <br />RECEIVE Y: <br />TITLE: !=' <br />F IiORIGINAL <br />PHONE: BECK: <br />HUT -3 <br />5/88 Cj m <br />■ <br />