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UNDERGROUP TANK PROGRAM OFFICIAL INSPI 'ION REPORT <br />,-..oAN JOAQUIN HEALTH DISTRICT - <br />1601 E. HAZELTON AVE. ^ <br />COUNTY NAME . J� n ' STOCKTON,CA 95205 CUUNTY # N <br />CJQSCA.I..�/ / PHnNF Nn dru_oe�q <br />SITE NAME: /y �� <br />S <br />INSPECTION DATE: / <br />SITE ADDRESS: J�% 1� <br />5-L <br />CITY/STATE/ZIP <br />s2�14v� CA 9".52,023 <br />CHANGES SITE/OWNER/PERMIT? YE NO <br />TANK <br />©l <br />TANK QZ_ <br />TANK <br />ANK <br />FORM A AND/OR B SUBMITTED? Al <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />TYPE.OF INSPECTION SITE CQMPUI R # <br />NUMBER <br />NUMBER <br />NUMBER <br />NUMBER <br />U ���'J(� <br />PER # <br />PER # <br />PER # <br />PER # <br />I �rlG // <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK mNK ....Ts <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 />-- <br />APPROVED MONITORING SYSTEM 9 10 <br />MONITORING SYSTEM 11 12 <br />APPROVED MONITOR FREQUENCY 13 14 <br />MONITORING RECORDS MAINTAINED 15 16 <br />ACCESS CASING SECURED 17 18 <br />PIPING 19 20 <br />- <br />✓ �— <br />_ _ <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 HAZARD 35 36 <br />CONDITIONS ABATED 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 43 <br />OWNER/OPERATOR MONITORING 44 45 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS 46 47 <br />PIPING 48 49 <br />FLAMMABLE VAPORS REMOVED 50 <br />UNAUTHORIZED RELEASE 51 52 <br />SAMPUNG 53 54 <br />IMPROPER ABANDONMENT 55 56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND YUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS: <br />Q <br />57 58 59 <br />MAJNO <br />❑ ❑ ❑ <br />VIOL VIOL VOL <br />OFFICE: <br />INSP: <br />RECEIVED BY: <br />Ltirlil <br />�tF�Z�t/ <br />TITLE: �� ,S' <br />PHONE: <br />RECK: <br />HUT -3 ORIGINAL 5/W ©1 <br />