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UNDERGROLW TANK PROGRAM OFFICIAL INSTION REPORT <br /> SAN JOAQUIN HEALTH DISTRIC <br /> 1601 E. HAZELTON AVE. <br /> COUNTY NAME STOCKTON, CA 95205 COUNTY # J� <br /> PHONE NO. 468-3423 <br /> SITE NAME: /?� T� INSPECTION DATE: p// 30 / <br /> SITE ADDRESS: 5-70 � /� rA� CITY/STATE/ZIP 3hc:G" C� 7 Sa6S <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK 0 / TANK TANK TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> TYPE O��F,,,,INSPECTION1575 <br /> Cy rrSITE COMPUTER# NUMBER NUMBER NUMBER NUMBER <br /> EXP.DATE JY EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK TANK CON NTs <br /> MAJOR MINOR <br /> PERMIT TO OPERATE 1 2 <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 7- <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 <br /> ACCESS CASING SECURED 17 18 45 <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 2S <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 VA <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL W4445 <br /> FLAMMABLE VAPORS REMOVED <br /> ACCESS LOCATIONS SEALED <br /> POWER DISCONNECTED <br /> OWNER/OPERATOR MONITORING <br /> PERMANENT TANK CLOSURE " <br /> REMOVAL OF RESIDUAL MATERIALS 46 47 <br /> PIPING 48 49 <br /> FLAMMABLE VAPORS REMOVED 50 <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: Q. 4717 112, <br /> 57 58 59 <br /> MAJNO <br /> VOR ElVIOLOR <br /> IOL ❑ VOL❑ <br /> OFFICE: INSP: RECEIVED BY: <br /> nLeA a'j) PHONE: RECK: <br /> HI UT-3 C-11GINAL =�'ae •�" <br />