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UNDERGROI�NK PROGRAM OFFICIAL INS ON REPORT N JOAQUIN HEALTH DISTRIC 1601 E. HAZELTON AVE. COUNTY NAME STOCKTON, CA 95205 COUNTY # q PHONE NO. 468-3423 // SITE NAME: INSPECTION DATE: �Ci SITE ADDRESS: CITY/STATE/ZIP CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK TANK TANK FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER TYPE OF INSPECTION SITE COMPUTER# NUMBER NUMBER NUMBER NUMBER PER# yWy-01 PER# PER# PER# EXP DATE EXP.DATE EXP.DATE EXP.DATE OPERATIONAL TANK TANK C4NTENTs MAJOR FIVIINOR PERMIT TO OPERATE 1 2 CHANGE IN CONDITIONS TO OPERATE 3 4 APPROVED CONSTRUCTION 5 6 WRITTEN MONITORING PROCEDURES 7 8 APPROVED MONITORING SYSTEM 9 10 MONITORING SYSTEM 11 12 - APPROVED MONITOR FREQUENCY 13 14 MONITCRWG RECORDS MAINTAINED 15 16 ACCESS CASING SECURED 17 18 PIPING 19 20 INVENTORY RECONCILIATION 21 22 tf TANK GAUGING 23 24 APPROVED RESPONSE PLAN 25 26 UNAUTHORIZED RELEASE OCCURRENCE 27 28 SAMPLING 29 30 APPROVED TANK REPAIRS 31 32 UNAUTHORIZED RELEASES REPORTED 33 34 SAFETY HAZARD 35 36 CONDITIONS ABATED 37 -- TEMPORARY TANK CLOSURE REMOVAL OF RESIDUAL 38 39 FLAMMABLE VAPORS REMOVED 40 ACCESS LOCATIONS SEALED 41 42 POWER DISCONNECTED 43 - _ OWNER/OPERATOR MONITORING 44 45 RMANENTTANK CLOSUR ' REMOVAL OF RESIDUAL MATERIALS 46 47 PIPING 48 49 FLAMMABLE VAPORS REMOVED 50 UNAUTHORIZED RELEASE 51 52 SAMPLING 53 54 ,^ IMPROPER ABANDONMENT 55 56 THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS SYSTEM STATUS(MUST MARK ONE) FOLLOWS; `- U 59 S 1 MAJOR 57 MINOR 58 NOCJs_ VIOL. ❑ VIOL. ❑ VIOL. 7- + �- OFFICE: INSP: C.G kot ()-z— IRECEIVED BY: TITLE: X55 PHONE: BECK: HUT-3 ORIGINAL