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UNDERGROUJ§TANK PROGRAM OFFICIAL INS REPORT <br /> SAN JOAQUIN HEALTH DISTRIC <br /> 1601 E. HAZELTON AVE. <br /> COUNTY NAME STOCKTON, CA 95205 COUNTY # ✓T <br /> PHONE NO. 468-3423 <br /> SITE NAME: P N DATE: �7 <br /> SITE ADDRESS: 5 Z SrCITY/STATE <br /> CHANGES SITE/OWNER/PERMIT? YES / NO TAN TANK TA TANK/ <br /> FORM A AND/OR B SUBMITTED? NUMBERE U L/ COMPUTEBER NUOMBET�KCOMPUT <br /> S IIEI�v� <br /> T OF INSPECTION SITE COMPUTER# PER# PER# 'q ER# PER# RRR"' � <br /> X/ EXP:DA � EXP.D v� XP:DAT P. <br /> DATE <br /> OPERATIONAL TANK <br /> TANK coNreNrs <br /> MAJOR MINOR <br /> PERMIT TO OPERATE 1 2 - <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 <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 <br /> i <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL 38 39 <br /> FLAMMABLE VAPORS REMOVED 40 <br /> ACCESS LOCATIONS SEALED 41 42 <br /> POWER DISCONNECTED 43 <br /> OWNER/OPERATOR MONITORING 144 45 <br /> PERMANENT TANK CLOSURE <br /> REMOVAL OF RESIDUAL MATERIALS 46 47 <br /> PIPING 48 49 _- <br /> M ._ <br /> FLAMMABLE VAPORS REMOVED 50 <br /> UNAUTHORIZED RELEASE 51 52 <br /> SAMPLING 53 54 <br /> IMPROPER ABANDONMENT 55 156 <br /> THE MARK MS REPRESENT VIOLATIONS AND MAST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONE) FOLLOWS <br /> 57 58 59 <br /> MAJORMINOR NO <br /> VIOL. ❑ VIOL. ❑ VIOL. <br /> 1 <br /> OFFICE: INS P: RECEIVE BY- <br /> TITLE: <br /> P ONE: BECK: <br /> NUT-3 ORIGINAL 5/88 ©M <br /> I� � <br />