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UNDERGROUN- TANK PROGRAM OFFICIAL INSPF^TION <br />._SAN JOAQUIN HEALTH DISTRICT . <br />1601 E. HAZELTON AVE. <br />Sly? �p� , <br />STOCKTON,NO. CA 95205 <br />COUNTY NAME <br />PHONE NO. 468-3423 <br />REPORT ry <br />COUNTY # "� 9 <br />SITE NAME: �fR LK <br />INSPECTIONDATE: <br />SITE ADDRESS: /3 7.5 <br />` _aCX) _�� , CITY/STATE/ZIP C� <br />I <br />CHANGES SITE/OWNER/PERMIT? <br />YES <br />NTO��`TANK <br />(0,5 TANK Q/ TANK TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER COMPUTE COMPUTER COMPUTER <br />NUMBER NUMBER NUMBER NUMBER <br />TYPE OF INSPECTION SITE COMPUTER # <br />1 " h� <br />PER # PER # PER # PER # <br />✓ "1 <br />EXP. DATE EXP. DATE EXP. DATE EXP. DATE <br />OPERATIONAL TANK <br />TANK <br />CONR:NlS <br />MAJOR I MINOR <br />PERMIT TO OPERATE <br />12 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 <br />4 <br />APPROVED CONSTRUCTION <br />5 <br />6 <br />_ <br />WRITTEN MONITORING PROCEDURES <br />7 <br />8 <br />APPROVED MONITORING SYSTEM <br />9 <br />10 <br />MONITORING SYSTEM <br />11 <br />12 <br />_ <br />APPROVED MONITOR FREQUENCY <br />13 <br />14 <br />MONITORING RECORDS MAINTAINED <br />15 <br />16 <br />ACCESS CASING SECURED <br />17 <br />18 <br />PIPING <br />19 <br />20 <br />INVENTORY RECONCILIATION <br />21 <br />22 <br />TANK GAUGING <br />23 <br />24 <br />APPROVED RESPONSE PLAN <br />25 <br />26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 <br />28 <br />SAMPLING <br />29 <br />30 <br />APPROVED TANK REPAIRS <br />31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 <br />34 <br />SAFETY HAZARD <br />35 <br />36 <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 />41 <br />42 <br />POWER DISCONNECTED <br />43 <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 />SAMPLING <br />53 <br />54 <br />IMPROPER ABANDONMENT <br />55 <br />56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS: <br />57 58 <br />59 <br />NO <br />❑ <br />❑ <br />VIOLOR <br />VIOLOR❑ VIOL <br />OFFICE: <br />INSP: <br />RECEIVED BY: <br />TITLE: <br />PHONE: <br />PECK: <br />HUT -3 ORIGINPL 5/55 OM <br />