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r`, <br /> UNDERGRO I TANK PROGRAM OFFICIAL. INS �'CTI <br /> .1.1 ON REPORT <br /> SAN JOAQUIN HEALTH DISTRI <br /> 1601 E. HAZEL TO AV , <br /> COUNTY NAME STOCKTON, CA 95205 <br /> { - PHONE No. 468.3423 COUNTY # <br /> SITE NAME: , <br /> INSPECTION DATE: 'O/d <br /> I SITE ADDRESS: {I <br /> p y CITY/STATE/ZIP <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK"' TANK TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> TYPE OF INSPECTION 51TE COMPUTER# NUMBER NUMBER NUMBER NUMBER <br /> PER PER#:i PER# PER# <br /> v Y3 EXP.DATE� EXP.DATE EXP,DATE EXP.DATE <br /> OPERATIONAL TANK TANK CONTENTs <br /> MAJOR MINOR <br /> PERMIT TO OPERATE �� .:".. � <br /> 1 1 <br /> CHANGE 1N CONDITIONS TO OPERATE 3 4 I' <br /> APPROVED CONSTRUCTION 5 6 If <br /> WRITTEN MONITORING PROCEDURES 7 g I; <br /> APPROVED MONITORING SYSTEM 19 10 II <br /> MONITORING SYSTEM 11 12 13 ; <br /> APPROVED MONITOR FREQUENCY 13 114 I, } <br /> MONITORING RECORDS MAINTAINED 15 16 � Il <br /> ACCESS CASING SECURED 17 18 <br /> PIPING 19 120 h <br /> INVENTORY RECONCILIATION 21 122 <br /> TANK GAUGING 23 24 I <br /> APPROVED RESPONSE PLAN 25 26 1{ <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 28 II <br /> SAMPLING 29 30 {l <br /> APPROVED TANK REPAIRS 31 32 <br /> ? UNAUTHORIZED RELEASES REPORTED 33 34 –__— <br /> SAFETY HAZARD 35 36 {i <br /> CONDITIONS ABATED 37 <br /> t <br /> 's'r 55.. -m,•r �:a,:.• <br /> I TEMPORARY TANK CLOSURE , - `rr40 <br /> n� <br /> 4-22REMOVAL OF RESIDUAL 38 139 II <br /> FLAMMABLE VAPORS REMOVED 40 _ <br /> ACCESS LOCATIONS SEALED 41 42 <br /> POWER DISCONNECTED 43 <br /> OWNER/OPERATOR MONITORING 44 45 I <br /> P ENT TANK CLOSURE ��> qwAli ,.... _ .. ... z" ll ...'� Kiska` s#r, x A s a.: ✓. , m4 <br /> REMOVAL OF RESIDUAL MA 46 47 I� _ <br /> PIPING 48 49 i <br /> FLAMMABLE VAPORS REMOVED 50 i� <br /> UNAUTHORIZED RELEASE 51 52 I� <br /> SAMPLING 53 54 N _ <br /> IMPROPER ABANDONMENT 55 56 II � <br /> THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS F <br /> (SYSTEM STATUS(MUST MARK ONE) FOLLOWS: y I A-z. O I <br /> li <br /> MAJOR 57 MINOR 58 NO <br /> VIOL. E] MINOR <br /> ❑ VIOL. f <br /> {F <br /> { fff <br /> 1� F <br /> OFFICE: INSP. (2 O RECEIVED Y: } <br /> �I <br /> TITLE: , �� l S PHONE: RECK: <br /> _iUT-3 ORIGINAL sig OM 1 <br />