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UNDERGROUNI -'kNK PROGRAM OFFICIAL INSPECT" ON REPORT <br />,N JOAQUIN HEALTH DISTRICT <br />f^, 1601 E. HAZELTON AVE. <br />nnuury URNIC 1 I� _ STOCKTON,CA 95205 COUNTY # 3� <br />uuun". nm <br />'1164, <br />rnvrv� - <br />SITE NAME: <br />INSPECTION DATE: <br />SITE ADDRESS: <br />CITY/STATE/ZIP <br />S SIT /OWNER/PERMIT? <br />CHANGESE <br />Y S <br />TANK TANK <br />TANK TANK <br />COMPUTER �j COMPUTER <br />COMPUTER COMPUTER <br />FORM AAND/OR B SUBMITTED? <br />NUMBER NUMBER <br />NUMBER NUMBER <br />TYPE OF INSPECTION SITE CO//,M,/` <br />TER # <br />PER # PER # <br />PER # PER # <br />116 v <br />EXP. DATE EXP. DATE <br />EXP. DATEMNK EXP. DATE <br />OPERATIONAL TANK <br />cOR <br />R <br />MAAJMINOorMINOs <br />PERMIT TO OPERATE <br />1 <br />2 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 <br />4 <br />APPROVED CONSTRUCTION <br />5 <br />6 <br />WRITTEN MONITORING PROCEDURES <br />7 <br />8 <br />APPROVED MONITORING SYSTEM <br />9 <br />10 <br />MONITORING SYSTEM <br />11 <br />12 <br />APPROVED MONITOR FREQUENCY <br />13 <br />14 <br />MONITORING RECORDS MAINTAINED <br />15 <br />116 <br />ACCESS CASING SECURED <br />17 <br />118 <br />PIPING <br />19 <br />120 <br />INVENTORY RECONCILIATION <br />21 <br />122 <br />TANK GAUGING <br />23 <br />124 <br />APPROVED RESPONSE PLAN <br />25 <br />126 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 <br />28 <br />_ <br />SAMPLING <br />29 <br />30 <br />_ <br />APPROVED TANK REPAIRS <br />31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 <br />34 <br />SAFETY HAZARD <br />35 <br />38 <br />CONDITIONS ABATED <br />37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />38 <br />39 <br />FLAMMABLE VAPORS REMOVED <br />40 <br />ACCESS LOCATIONS SEALED <br />4142 <br />POWER DISCONNECTED <br />43 <br />_ <br />OWNER/OPERATOR MONITORING <br />44 <br />45 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />46 <br />47 <br />PIPING <br />48 <br />49 <br />FLAMMABLE VAPORS REMOVED <br />50 <br />UNAUTHORIZED RELEASE <br />51 <br />52 <br />SAMPUNG <br />53 <br />54 <br />IMPROPER ABANDONMENT <br />55 <br />56 <br />THE MARKED ITEMS REPRESENT VIOLAnOto <br />AND UST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS: <br />57 58 <br />59 <br />MINOR NO <br />❑ ❑ <br />VIOL" VIOL VIOL <br />OFFICE: <br />INSP� <br />RECEIVED BY: <br />PHONE: <br />BECK: <br />/ <br />TITLE:�.L.LS <br />R«`((( <br />HUT -3 ORIGINAL Sias ©M <br />