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COUNTY NAME <br />UNDERGROU9 TANK PROGRAM OFFICIAL INS ON REPORT <br />SAN JOAOUIN HEALTH DISTRIC <br />1601 E. HAZELTON AVE. <br />STOCKTON, CA 95205 COUNTY 1 <br />PHONE NO. 468-3423 <br />1151 -3C q�- <br />�Vlc,�r•rr'a , <br />"; <br />A hin O0 A <br />SITE NAME: <br />INSPECTION DATE: <br />SITE ADDRESS: <br />CITY/STATE/ZIP <br />M <br />CHANGES SITE/OWNER/PERMIT? <br />YES <br />NO <br />TANK 113®_1 TANK 1 jqo -Z <br />TANK 1/30 -3 T NK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTE COMPUTER ee� '' <br />COMPUTE CO LITER <br />NUMB <br />NUMBER; NUMBER NUMBER c�t//t <br />NUMBER ,r(�jC(L� <br />TYPE OF INSPECTION SITE COMPUTER <br /># <br />PER # ✓ PER # <br />PER # ER # <br />111-50 <br />EXP. DATE EXP. DATE <br />EXP. DATE DATE <br />OPERATIONAL TANK <br />TANK CONTENTS <br />MAJOR MINOR <br />PERMIT TO OPERATE <br />1 <br />2 <br />CHANGE IN CONDITIONS TO OPERATE <br />3 <br />4 <br />APPROVED CONSTRUCTION <br />5 <br />6 <br />WRITTEN MONITORING PROCEDURES <br />7 <br />8 <br />APPROVED MONITORING SYSTEM <br />9 <br />10 <br />MONITORING SYSTEM <br />11 <br />12 <br />APPROVED MONITOR FREQUENCY <br />13 <br />14 <br />MONITORING RECORDS MAINTAINED <br />15 <br />16 <br />ACCESS CASING SECURED <br />17 <br />18 <br />PIPING <br />19 <br />20 <br />INVENTORY RECONCILIATION <br />21 <br />22 <br />TANK GAUGING <br />23 <br />24 <br />APPROVED RESPONSE PLAN <br />25 <br />26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 <br />28 <br />SAMPLING <br />29 <br />30 <br />APPROVED TANK REPAIRS <br />31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED <br />33 <br />34 <br />SAFETY HAZARD <br />35 <br />36 <br />CONDITIONS ABATED <br />37 <br />n <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />38 <br />39 <br />77 <br />FLAMMABLE VAPORS REMOVED <br />40 <br />777,1 <br />ACCESS LOCATIONS SEALED <br />41 <br />42 <br />� <br />POWER DISCONNECTED <br />43 <br />_..___. <br />OWNER/OPERATOR MONITORING <br />44 <br />45 <br />1 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />46 <br />47 <br />PIPING <br />48 <br />49 <br />FLAMMABLE VAPORS REMOVED <br />50 <br />UNAUTHORIZED RELEASE <br />51 <br />52 <br />SAMPLING <br />53 <br />54 <br />IMPROPER ABANDONMENT <br />155 <br />156 <br />THE MARKED ITEMS RE RESENT VIOLATIONS AND MU_*T BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FO OWS: <br />MAJOR 57 MINOR NO <br />❑ <br />59 <br />❑ <br />FIL-' T <br />C <br />VIOL. VIOL. VIOL. <br />OFFICE: <br />INSP: <br />RECEIVE <br />TITLE: <br />PHONE: <br />BECK: <br />HUT -3 ORIGINAL 5/88 n t <br />