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UNDERGROU"I TANK PROGRAM OFFICIAL INSF :TION REPORT _ SAN JOAQUIN HEALTH DISTRICT - 1601 E. HAZELTON AVE. STOCKTON, CA 95205 COUNTY # 3 COUNTY NAME Shy �lq UjA) PHONE NO. 468-3423 SITE NAME: INSPECTION DATE: SITE ADDRESS: CRY/STATE/ZIP RANGES SITE/OWNER/PERMIT? YES NO IANK TANK §7 TANK TANK COMPUTERCOMPUTER_� COMPUTER COMPUTER COMPUTER FORM A AND/OR B SUBMITTED? NUMBER g NUMBER p- � NUMBER NUMBER TYPE OF INSPECTION SITE COMPUTER# �'r 'Z T,e,6�1ia( PER, a�j�_0 PER# 'aI ) PER# PER# j EXP.DATE '7" EXP.DATE EXP.DATE EXP DATE K CONTENTS OPERATIONAL TANK MAJOR MINOR ..r- PERMIT TO OPERATE 1 2 ---- --- CHANGE IN CONDITIONS TO OPERATE 3 4 APPROVED CONSTRUCTION 5 6 WRITTEN MONITORING PROCEDURES 7 8 _ APPROVED MONITORING SYSTEM 9 10 - MONITORING SYSTEM 11 12 .. APPROVED MONITOR FREQUENCY 13 14 _ MONITORING RECORDS MAINTAINED 15 16 ACCESS CASING SECURED 17 18 PIPING 19 20 _ _ - INVENTORY RECONCILIATION 21 22 ---. TANK GAUGING 2324 APPROVED RESPONSE PLAN 25 26 UNAUTHORIZED RELEASE OCCURRENCE 27 28 SAMPLING 29 APPROVED TANK REPAIRS 31 32 UNAUTHORIZED RELEASES REPORTED 33 34 SAFETY HAZARD 135 136 CONDITIONS ABATED 37 TEMPORARY TANK CLOSURE REMOVAL OF RESIDUAL w4445 _ FLAMMABLE VAPORS REMOVED ACCESS LOCATIONS SEALED POWER DISCONNECTED OWNER/OPERATOR MONITORING PERMANENT TANK CLOSURE REMOVAL OF RESIDUAL MATERIALS 46 47 PIPING 48 49 FLAMMABLE VAPORS REMOVED 50 V UNAUTHORIZED RELEASE 51 52 SAMPLING 53 54 IMPROPER ABANDONMENT 55 56 THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS SYSTEM STATUS(MUST MARK ONE) FOLLOWS: 57 68 59 VIOLOR ❑ VIOLOR ❑ VOL.NO ❑ OFFICE: SP: RECEIVED BY: TI LE PHONE: BECK: HUT-3 ORIGINAL 5/88