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UNDERGROUTANK PROGRAM OFFICIAL INSP ION REPORT <br />AN JOAQUIN HEALTH DISTRICT <br />1601 E. HAZELTON AVE. <br />COUNTY NAME STOCKTON, CA 95205 COUNTY # <br />PHONE NO. 468-3423 <br />SITE NAME: <br />INSPECTION DATE: <br />t66 <br />SITE ADDRESS: �f <br />S" <br />CITY/STATE/ZIP <br />5- L/Lim, <br />CHANGES SITE/OWNER/PERMIT? <br />YES NO <br />TANK <br />TANK <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />COMPUTER <br />NUMBER <br />NUMBER <br />NUMBER <br />NUMBER <br />TYPE 0 INSPECTION <br />SITE COMPUTER # <br />PER # <br />PER # <br />PER # <br />PER # <br />a <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />TANK CONTENTS <br />' <br />MAJOR MINOR <br />PERMIT TO OPERATE <br />1 2 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 4 <br />APPROVED CONSTRUCTION <br />5 6 <br />WRITTEN MONITORING PROCEDURES <br />7 8 <br />APPROVED MONITORING SYSTEM <br />9 10 <br />MONITORING SYSTEM <br />11 12 <br />APPROVED MONITOR FREQUENCY <br />13 14 <br />MONITORING RECORDS MAINTAINED <br />15 16 <br />ACCESS CASING SECURED <br />17 18 <br />SLj <br />PIPING <br />19 20 <br />/}tj <br />INVENTORY RECONCILIATION <br />TANK GAUGING <br />21 22 <br />23 24 <br />APPROVED RESPONSE PLAN <br />25 26�d <br />- <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 28 <br />-- <br />- <br />SAMPLING <br />29 30 <br />APPROVED TANK REPAIRS <br />31 32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 34 <br />SAFETY HAZARD <br />35 36 <br />— <br />CONDITIONS ABATED <br />37 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />38 39 <br />FLAMMABLE VAPORS REMOVED <br />40 <br />ACCESS LOCATIONS SEALED <br />41 42 <br />POWER DISCONNECTED <br />43 <br />OWNER/OPERATOR MONITORING <br />44 45 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />47 <br />PIPING <br />49 <br />FLAMMABLE VAPORS REMOVED <br />r5l <br />UNAUTHORIZED RELEASE <br />52SAMPLING <br />54IMPROPER <br />ABANDONMENT <br />56 <br />THE MARKED ITEMS REPRESFNT_VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FO LOWS: <br />t <br />57 58 <br />59 <br />MAJOR ❑ MINOR ❑ NO <br />Li <br />VIOL VIOL. VOL <br />w ' <br />c <br />4 <br />i <br />n G <br />OFFI E: <br />IN <br />RCE BY: <br />TITLE:- <br />�L <br />PHO : <br />REC <br />HUT -3 ORIGINAL <br />