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UNDERGROUN ANK PROGRAM OFFICIAL INSPETION REPORT <br />AN JOAQUIN HEALTH DISTRICT fj <br />1601 E. HAZELTON AVE. <br />COUNTY NAME STOCKTON, CA 95205 3c� <br />VrUt'i�% PHONE NO. 468-3423 COUNTY # <br />SITE NAME: <br />INSPECTION DATE: <br />SITE ADDRESS: y�� ? fo <br />CITY/STATE/ZIP <br />S IV <br />5;4- <br />CHANGES SITE QfS NO <br />CdPS <br />TANK <br />TANK <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />NUMBER <br />COMPUTER <br />NUMBER <br />COMPUTER <br />NUMBER <br />COMPUTER <br />NUMBER <br />TYPE OF INSPECTION <br />ISITE COMPUTER # <br />PER # <br />PER # <br />PER # <br />PER # <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK m KCONTEN� <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 />- <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 HAZARD35 36 <br />CONDITIONS ABATED 37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL 1 139 <br />FLAMMABLE VAPORS REMOVED <br />ACCESS LOCATIONS SEALED <br />W4445 <br />POWER DISCONNECTED <br />OWNER/OPERATOR MONITORING <br />PERMANENT TANK CLOSURE <br />gin <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) <br />FOLLOWS: <br />57 58 59 <br />MAJOR MINOR NO <br />❑ ❑ <br />VIOL. VIOL. VIOL. L•J <br />OFFICE: <br />INSP:n <br />RECEIVED BY: <br />TITLE: �Q� NS <br />PHONE: <br />BECK: <br />HUT -3 <br />FILE COPY <br />5/88 OM <br />