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UNDERGROUN!' YANK PROGRAM OFFICIAL INSF "'--90N REPORT Q.,AN JOAQUIN HEALTH DISTRIC14 + 1601 E. HAZELTON AVE. COUNTY NAME J L [A D STOCKTNO. CA`95205 -3423 COUNTY # �—1 PHONE NO. 468-3423 SITE NAME: U S S p INSPECTION DATE: ` 5f SITE ADDRESS: r'yl CITY/STATE/ZIP o CHANGES SITE/OWNER/PERMIT? YES NO TANK 0 E ,TANK TANK TANK FORM A AND/OR B SUBMITTED? COMPUTER: COMPUTER COMPUTER COMPUTER TYPE OF INSPECTION SITE COMPUTER# NUMBER NUMBER NUMBER NUMBER . PER # PER# PER# C.�CPER# i SU EXP.RATE ,I EXP.DATE EXP.DATE EXP.DATE raneKcoNrErsrs � � �� ~tazr3 MAJOR MINOR OPERATIONAL TANK I41lx� t > 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 MONITORING RECORDS MAINTAINED 15 16 _ ACCESS CASING SECURED 17 18 PIPING 19 120 INVENTORY RECONCILIATION 21 22 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 35 136 CONDITIONS ABATED 37 �. TEMPORARY TANK CLOSURE �" a �' OR , c REMOVAL OF RESIDUAL 38 39 FLAMMABLE VAPORS REMOVED 40 ACCESS LOCATIONS SEALED 41 42 POWER DISCONNECTED 43 OWNER/OPERATOR MONITORING 44 45 sa PERMANENT TANK CLOSURE k 4 b � � � � � � a ..a tsV 4 p ` REMOVAL OF RESIDUAL MATERIALS 46 47 PIPING 48 49 FLAMMABLE VAPORS REMOVED 50 UNAUTHORIZED RELEASE 51 52 SAMPLING 53 54 _ T_ - IMPROPER ABANDONMENT 55 58 lih THE"MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS SYSTEM STATUS(MUST MARK ONE) FOLLOWS: py I i,--" Cc, MAJOR . 57 MINOR 58 NO 59 X` r vL -� VIOL. ❑ VIOL- ❑ VIOL- OFFICE: INSP• RECEIVED BY: TITLE: L �u'� PHONE: RECK: HUT-3 ORIGINAL siss O