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i <br /> UNDERGROti SANK PROGRAM OFFICIAL INS' "` .ION REPORT 5� k <br /> SAN JOAQUIN HEALTH DISTRIG <br /> 1601 E. HAZELTON AVE:, <br /> COUNTY NAME STOCKTON, CA 95205 COUNTY # <br /> PHONE NO, 468-3423 <br /> SITE NAME: L PS14 0 - INSPECTION DATE: �3 <br /> SITE ADDRESS: ] A CITY/STATE/ZIP <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK S/ TAN TANK <br /> FORM A AND/ORB SUBMITTED? COMPUTER COMPUTER COMPUT R WMPUTER <br /> TYPE OF INSPECTION SITE COMPUTER# NUMBER aj O NUMBER Zs BER � c� MBER <br /> PER# PER# PER # !�� PER # <br /> EXP.RATE VEXP.DATE EXP.DATE -EXP.DATE <br /> OPERATIONAL TANK TANK CONTENTS ' R ,; f� <br /> MAJOR MINORt� ? � ��� C' V <br /> PERMIT TO OPERATE 1 2 <br /> CHANGE 1N CONDITIONS TO OPERATE 3 4 <br /> APPROVED CONSTRUCTION 5 6 t <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 <br /> PIPING 19 20 <br /> INVENTORY RECONCILIATION 21 22 <br /> s <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 35 136 <br /> CONDITIONS ABATED 37Rx <br /> i a4 �g <br /> TEMPORARY TANK CLOSURES` <br /> REMOVAL OF RESIDUAL 38 39 <br /> FLAMMABLE VAPORS REMOVED 40 - <br /> ACCESS LOCATIONS SEALED 41 42 _ <br /> POWER DISCONNECTED <br /> OWNER/OPERATOR MONITORING 44 45 <br /> PERMANENT TANK CLOSURE �. w � , <br /> REMOVAL OF RESIDUAL MATERIALS 46 47 <br /> PIPING 48 49 <br /> -- i <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 r I <br /> SYSTEM STATUS{MUST MARK ONE} FOLLOWS: li <br /> i <br /> MAJOR 57 MINOR 58 69 <br /> NO <br /> VIOL. ❑ VIOL. ❑ VIOL <br /> OFFICE: INSP: RECEIVED BY: <br /> TITL ]� PHONE: FIECK: { <br /> HUT-3 ORIGINAL 1 `. ORIGINAL <br />