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' UNDERGROU&TANK PROGRAM OFFICIAL INS REPORT SAN JOAQUIN HEALTH DISTRICT 1601 E. HAZELTON AVE. STOCKTON, CA 95205 CDUNTY LINTY NAME PHONE NO. 468-3423 #3? SITE NAME: P®r+ o-- S �c INSPECTION DATE: 7LI 0 SITE ADDRESS: o ( � wall v' CITY/STATE/ZIP �, S�(� CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK TANK TANK FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER NUMBER NUMBER NUMBER NUMBER TYPE OF INSPECTION SITE COMPUTER# PER# PER# PER# PER # Jc {� EXP.DATE EXP DATE EXP DATE EXP DATE TANK CONTENTS OPERATIONAL TANKy, >. 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 13 114 MONITORING RECORDS MAINTAINED 15 116 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 HAZARD35 36 CONDITIONS ABATED 37 x. TEMPORARY TANK CLOSUREf�': REMOVAL OF RESIDUAL 38 139 FLAMMABLE VAPORS REMOVED 40 ACCESS LOCATIONS SEALED 41 42 - - POWER DISCONNECTED 43 ---- OWNER/OPERATOR MONITORING 44 45 7e� _+��- .F PERMANENT TANK CLOSURE `" `A REMOVAL OF RESIDUAL MATERIALS 46 147 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: f 0 lyl ri re 57 58 59 53- MAJOR NO VIOL. ❑ VIOL MINOR ❑ VOL.❑ OFFICE: INS VRECEIVED BY: TITLE: PHONE: BECK: WI IT-'A ORIGINAL