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UNDERGRO' N"-TANK PROGRAM OFFICIAL INF"r---ION REPORT <br /> SAN JOAQUIN HEALTH DISTRIX' <br /> �. 1601 E. HAZELTON AVE. <br /> "BOUNTY DAME Sa v STOCKTON, CA 95205 COUNTY # <br /> Q .(/jiLa PHONE NO. 468"3423 <br /> SITE NAME: �p�/G � /r° s er o !`G INSPECTION DATE: <br /> SITE ADDRESS: 3 5 CITY/STATE/ZIP C4 7 jp7 <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK (>� TANK ('(o TANK D 7 ! TANK d?' <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> TYPE OF INSPECTION SITE COM ER# NUMBER NUMBER NUMBER NUMBER <br /> : Ro PER# /Q oo PER # /490® PER# 196W PER# <br /> I �W EXP,DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK TANK CONTENTS <br /> MAJOR MINOR <br /> PERMIT TO OPERATE 1 2 <br /> CHANGE IN CONDITIONS TO OPERATE 3 4 - <br /> APPROVED CONSTRUCTION 5 6 -- <br /> WRITTEN MONITORING PROCEDURES 7 g <br /> APPROVED MONITORING SYSTEM 9 10 _- <br /> MONITORING SYSTEM 11 12 <br /> APPROVED MONITOR FREQUENCY E2122 <br /> - <br /> MONITORING RECORDS MAINTAINED <br /> ACCESS CASING SECURED <br /> PIPING /-/- C aukco4-% <br /> INVENTORY RECONCILIATION - - - <br /> TANK GAUGING 23 24 __-- - -- <br /> APPROVED RESPONSE PLAN 25 26 <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 28 T - <br /> SAMPLING 29 30 .- <br /> APPROVED TANK REPAIRS 31 132 <br /> UNAUTHORIZED RELEASES REPORTED 33 134 <br /> SAFETY HAZARD 35 36 <br /> CONDITIONS ABATED 37 <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL 38 39 <br /> FLAMMABLE VAPORS REMOVED 40 <br /> ACCESS LOCATIONS SEALED 41 42 <br /> POWER DISCONNECTED ' / 43 <br /> OWNER/OPERATOR MONITORING 44 45 <br /> PERMANENT TANK CLOSURE <br /> REMOVAL OF RESIDUAL MATERIALS 46 47 - <br /> PIPING 48 49 <br /> FLAMMABLE VAPORS REMOVED 50 <br /> UNAUTHORIZED RELEASE 51 52 <br /> SAMPLING 53 4 <br /> IMPROPER ABANDONMENT 55 56 <br /> THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONE) FOLLOWS: <br /> 7 59 <br /> MAJOR SIY MINOR NO <br /> VIOL. LL�� VTOL. VIOL. <br /> El <br /> OFFICE: INSP: /d _ <br /> TITLE& ' oww REC <br /> HUT-3 III" <br /> OP .1NIA; �/1�I�. ^ r )'11'A n Ait srna 0- <br />