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r <br /> UNDERGROUNr'-TANK PROGRAM OFFICIAL INSPE--ION REPORT <br /> AN JOAQUIN HEALTH DISTRICT - <br /> 1601 E. HAZELTON AVE. <br /> COUNTY NAME STOCKTON, CA 95205 COUNTY # 3 <br /> PHONE NO. 468-3423 <br /> SITE NAME: ' < S INSPECTION DATE: <br /> SITE ADDRESS: Z 7 7- pp��, <br /> r, '.ZCITY/STATE/ZIP � 9`3'�L� <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK k TANK TANK J7) TANK <br /> FORM AAND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTrl <br /> TYPE OF IN PECTION SITE COMPUTER# NUMBER NUMBER NUMBER NUMBER <br /> 77( PER# PER# PER # PER# <br /> EXP.DATE EXP.DATE EXP.DATE EXP-DATE <br /> OPERATIONAL TANK TANK CONTENTS <br /> MA OR MINOR <br /> PERMIT TO OPERATE 1 2 X <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <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 FREQUENCY 13 14 <br /> MONITORING RECORDS MAINTAINED 15 16 X J X <br /> ACCESS CASING SECURED 17 18 <br /> PIPING 19 20 <br /> INVENTORY RECONCILIATION 21 22 — <br /> TANK GAUGING 23 24 <br /> APPROVED RESPONSE PLAN 25 26 <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 28 <br /> SAMPLING 29 30 <br /> APPROVED TANK REPAIRS 31 32 — <br /> UNAUTHORIZED RELEASES REPORTED 33 34 <br /> SAFETY HAZARD 35 36 <br /> CONDITIONS ABATED 37 FA <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL 38 39 <br /> FLAMMABLE VAPORS REMOVED 40 <br /> ACCESS LOCATIONS SEALED 41 42 <br /> POWER DISCONNECTED MM 43 _ <br /> OWNER/OPERATOR MONITORING 44 45 <br /> PERMANENT TANK CLOSURE <br /> REMOVAL OF RESIDUAL MATERIALS 46 47 <br /> PIPING 48 49 - <br /> FLAMMABLE VAPORS REMOVED 50 ME <br /> UNAUTHORIZED RELEASE 51 52 _ <br /> SAMPLING 53 54 <br /> IMPROPER ABANDONMENT 55 56 <br /> THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONE) FOLLOWS: Z <br /> MAJOR 57 MINOR 58 NO 59 <br /> VIOL. VIOL. ❑ VIOL.❑ <br /> OFFICE: INS P: RECEIVED BY <br /> TITLE:�/ � ON : RE : <br /> HUT-3 ORIGINAL siea OM <br />