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UNDERGROU►' NK PROGRAM OFFICIAL INSP,'"TION REPORT SAN JOAOUIN HEALTH DISTRICT- 1601 E. HAZELTON AVE. COUNTY # 3 STOCKTON, CA 95205 COUNTY NAMEr�,�,� �or8�v/�C/ PHONE NO. 468-3423 f I INSPECTION DATE: rf q c� SITE NAME: / CITY/STATE/ZIP,,I-azie SITE ADDRESS: TANK Z TANK J TANK �� CHANGES SITE/OWNER/PERMIT? YES NO COMPUTER COMPUTER COMPUTER COB ER FORM A AND/OR B SU11 BMITTED? NUMBER NUMBER NUMBER PER#- PER# PER# TYPE OF INSPECTION SITE COMPUTER# PER# EXP.DATE EXP DATE� EXP DATE EXP DATE TANK CONTENTS OPERATIONAL TANK MAJOR MINOR 1�= 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 19 20 PIPING INVENTORY RECONCILIATION 21 22 23 24 TANK GAUGING - APPROVED RESPONSE PLAN 25 26 UNAUTHORIZED RELEASE OCCURRENCE 30 29 SAMPLING 3i 32 APPROVED TANK REPAIRS 33 � -_ � UNAUTHORIZED RELEASES REPORTED 35 36 SAFETY HAZARD 37 `- CONDITIONS ABATED TEMPORARY TANK CLOSURE 38 39 REMOVAL OF RESIDUAL -- FLAMMABLE VAPORS REMOVED 40 41 42 ACCESS LOCATIONS SEALED - 43 POWER DISCONNECTED -- OWNER/OPERATOR MONITORING 44 45 p NENT TANK CLOSURE 4 MATERIALS 6 47 REMOVAL OFR 46 49 _ — ---- ----- PIPING 50 _ --- FLAMMABLE VAPORS REMOVED — ---- UNAUTHORIZED RELEASE 51 52 - - SAMPLING 53 55 54 IMPROPER ABANDONMENT THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS SYSTEM STATUS(DUST MARK ONE) FOLLOWS: 57 � 59 MINOR MAJOR ❑ NO VIOL. VIOL VIOL.❑ OFFICE: INSP: �� RECEIVED BY: / PHONE: BECK: TITLE: �.C�'' � ' sea ORIGINAL