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UNDERGROUNMFANK PROGRAM OFFICIAL INSP ON REPORT <br />'USAN JOAQUIN HEALTH DISTRICT <br />1601 E. HAZELTON AVE. <br />COUNTY NAME, �� y, STocKTON,CA 95205 PnuurY ,64 <br />"" 3 ORIGINAL <br />siea O <br />SITE NAME: <br />INSPECTION <br />DATE: ao 8y <br />SITE ADDRESS: <br />CITY/STATE/ZIPC <br />CHANGES SITE/OWNER/PERMIT? <br />YES <br />NO TANK <br />TANK TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTIIR <br />COMPUTER COMPUTER <br />COMPUTER <br />TYPE OF INSPECTIONSITE COMPUTER # <br />NUMBER <br />NUMBER NUMBER <br />NUMBER <br />PER # <br />PER # PER # <br />PER # <br />I� <br />EXP. DATE <br />EXP. DATE F_XP. DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />TANK CONTE � <br />MAJOR MINOR <br />PERMIT TO OPERATE <br />y <br />2 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 <br />4- <br />APPROVED CONSTRUCTION - <br />5 <br />6 <br />- <br />- "- <br />WRITTEN MONITORING PROCEDURES <br />7 <br />EF - <br />APPROVED MONITORING SYSTEM <br />9 <br />10 <br />MONITORING SYSTEM <br />71 <br />12 <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 />yg <br />2p <br />" <br />INVENTORY RECONCILIATION <br />21 <br />22 <br />- <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 />3g <br />- -- --- <br />FLAMMABLE VAPORS REMOVED <br />40 <br />ACCESS LOCATIONS SEALED <br />41 <br />42 <br />POWER DISCONNECTED <br />q3 <br />OWNER/OPERATOR MONITORING <br />44 <br />45 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />PIPING <br />FLAMMABLE VAPORS REMOVED <br />UNAUTHORIZED RELEASE <br />Dri <br />SAMPLING <br />-------- -- <br />IMPROPER ABANDONMENT <br />THE MARKED ITEMS REPR ENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS: <br />MAJOR 57 MINOR 58 NO <br />VIOL. El ❑ <br />5 <br />VIOL VIO <br />OFFICE: <br />INSP: <br />RECEIVED BY: <br />TITLE <br />/ <br />jlr I <br />PHONE: <br />BECK: <br />"" 3 ORIGINAL <br />siea O <br />