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UNDERGROUJ&TANK PROGRAM OFFICIAL INSTION REPORT <br /> SAI JRUIN HEALTH DISTRIC <br /> 1601 E. HAZELTON AVE. <br /> COUNTY IIAME SOW�� �� ` STOCKTON, CA 95205 COU ffy #3 <br /> Q <br /> (�+'� PHONE NO. 468-3423 / <br /> SITE NAME: Pa,r rr I s INSPECTION DATE: -.�,0 _13 <br /> SITE ADDRESS: OO IV_ ` i l jJ ITY/STATE/ZIP ls_6 <br /> CHANGES SITE/OWNER/PERMIT? -YES NO TANK TANK -)- TANK TANK <br /> FORM A AND/OR B SIIRMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> NUMBER NUMBER NUMBER NUMBER <br /> TYPE OF INSP CTION SITE COMPUTER#`'� PER# PER# PER# PER# <br /> Po u +�, �l o c 3 D I EXP.DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK rnNK CONTENTS <br /> MAJOR I 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 /> ACCFSS CASING SECURED 17 18 -- T <br /> PIPING 19 20 <br /> INVENTORY RECONCILIATION 21 22 � - -- -- <br /> TANK GAUGING 23 124 1 <br /> APPROVED RESPONSE PLAN 25 26 <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 28 <br /> SAMPLING 29 30 <br /> __- <br /> APPROVED TANK REPAIRS 31 32 <br /> UNAUTHORIZED RELEASES REPORTED 33 34 <br /> SAFETY HAZARD 135 136 <br /> CONDITIONS ABATED VZZ, 37 <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL 38 39 <br /> FLAMMABLE VAPORS REMOVED 40 <br /> ACCESS LOCATIONS SEALED 41 42 _ <br /> POWER DISCONNECTED ff45 <br /> OWNER/OPERATOR MONITORING 44 <br /> PERMANENT TANK CLOSURE ` <br /> RFMOVAL.OF RESIDUAL MATERIALS 46 47 <br /> PIPING 48 49 <br /> Fl AMMABLE 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 g <br /> SYSTEM STATUS(MUST MARK ONE) FOLLOWS: <br /> 57 58 59 <br /> MAJOR MINOR <br /> VIOL <br /> NO <br /> VIOL C� VIOL LJ VIOL.❑ - <br /> OFFICE INSP: ECEIVED BY: <br /> TITLE:� s PHONE: BECK: <br /> NUT-3 ORIGINAL 5188 (`>" <br />!77.. <br />