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UNDERGROUTANK PROGRAM OFFICIAL INSON REPORT VAN JOAQUIN HEAd1601 E. LTH DISTRICT . STOCKTON, CA 95205 COUNTY # COUNTY NAME PHONE NO, 468-3423 INSPECTION DATE: SITE NAME: SITE ADDRESS: CITY/STATE/ZIP rDA a TANK CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK FORM AAND/OR B SUBMITTED? COMPUTER COMBERER COMPUTE NUMBED NUMBER TYPE�OF INSP CT]ON SITE COMPUTeE�R# PER# / PER# PER# 1�7 / EXPO DART ._- EXP.DATE EXP.DATE - TANK CONTENTS OPERATIONAL TANK MAJOR MINOR PERMIT TO OPERATE 1 2 CHANGE IN CONDITIONS TO OPERATE 3 4 H _ g- :, ; _ APPROVED CONSTRUCTION 5 6Li 7 8 WRITTEN MONITORING PROCEDURES j r4 APPROVED MONITORING SYSTEM 9 10 _=t-a MONITORING SYSTEM 11 12 APPROVED MONITOR FREQUENCY 13 14 --- _ MONITORING RECORDS MAINTAINED 15 16 ACCESS CASING SECURED 17 18 -- PIPING 19 20 INVENTORY RECONCILIATION 21 22 — - --- TANK GAUGING 23 24 _— :.: It- 25 26 APPROVED RESPONSE PLAN UNAUTHORIZED RELEASE OCCURRENCE 27 28 r' SAMPLING 29 ,._. APPROVED TANK REPAIRS 31 32H _ - UNAUTHORIZED RELEASES REPORTED 33 34 36 SAFETY HAZARD — CONDITIONS ABATED 371= -' I TEMPORARY TANK CLOSURE _ 39 REMOVAL OF RESIDUAL 38 FLAMMABLE VAPORS REMOVED 40 — ACCESS LOCATIONS SEALED 41 42 POWER DISCONNECTED' 43 OWNER/OPERATOR MONITORING 44 45 PERMANENT TANK CLOSURE REMOVAL OF RESIDUAL MATERIALS 46 47 PIPING 48 49 FLAMMABLE VAPORS REMOVED 50 52 UNAUTHORIZED RELEASE 51 SAMPLING 53 54 _ — — IMPROPER ABANDONMENT 55 56 THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS SYSTEM STATUS(MUST MARK ONE) FOLLOWS: 57 MINOR 58 NO 59 MAJOR VIOL. VIOL. El VIOL. OFFICE: INSP RECEIVED BY: p // J�� ✓YI1 PNONE CK 7 6i 033 TITLE: siss C ,IJT_3 ORIGINAL