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UNDERGROU ANK PROGRAM OFFICIAL INSP ION REPORT / d <br />AN JOAQUIN HEALTH DISTRICT <br />1601 E. HAZELTON AVE. <br />COUNTY NAME STOCKTON, CA 95205 COUNTY # <br />PHONE NO. 468-3423 <br />SITE NAME: <br />INSPECTION DATE: <br />,(fS <br />Q <br />SITE ADDRESS:'10�rX72!r <br />CITY/STATE/ZIP <br />CHANGES SITE/OWNER/PERMIT? <br />YES <br />NO <br />TANK <br />TANK <br />TANK <br />TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTE <br />COMP <br />COMPUTER <br />COMPUTER <br />COMPU19 <br />NUMBER <br />PER # <br />NUMBER <br />PER # <br />NUMBER <br />PER # <br />NUMBER <br />PER # <br />TYPE F INSPE TION SITE COMPUTER # <br />/7 <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />EXP. DATE <br />OPERATIONAL TANK <br />TANK CONTENTS <br />MAJOR I MINOR <br />PERMIT TO OPERATE <br />_!z <br />2 <br />wy <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 />_ <br />APPROVED MONITORING SYSTEM <br />9 <br />10 <br />MONITORING SYSTEM <br />11 <br />12 <br />APPROVED MONITOR FREQUENCY <br />13 <br />14 <br />_ <br />MONITORING RECORDS MAINTAINED <br />15 <br />16 <br />_ M <br />ACCESS CASING SECURED <br />17 <br />18 <br />_y <br />PIPING <br />19 <br />20 <br />-_ <br />INVENTORY RECONCILIATION <br />22 <br />TANK GAUGING <br />r23�' <br />24 <br />APPROVED RESPONSE PLAN <br />25 <br />26 <br />UNAUTHORIZED RELEASE OCCURRENCE <br />27 <br />28 <br />W4 <br />SAMPLING <br />29 <br />30 <br />_.. <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 />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />38 <br />39 <br />FLAMMABLE VAPORS REMOVED <br />40 <br />ACCESS LOCATIONS SEALED <br />41 <br />42__ <br />A ry <br />a <br />POWER DISCONNECTED <br />43 <br />OWNER/OPERATOR MONITORING <br />44 <br />45 <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />47 <br />PIPING <br />49 <br />FLAMMABLE VAPORS REMOVED <br />r5l <br />UNAUTHORIZED RELEASE <br />52 <br />.SAMPLING <br />54 <br />IMPROPER ABANDONMENT <br />56 <br />THE MARKED ITEMS <br />REPRESENT VIOLATIONS AND MUST BE CORRECTED <br />AS <br />SYSTEM STATUS (MUST MARK ONE) <br />FOLLOWS: <br />57 58 <br />59 <br />MAJOR MINOR NO <br />❑ <br />❑ <br />VIOL. VIOL. VIOL. <br />OFFICE: <br />INSP: <br />RprEIVE <br />BY: <br />TITLE: <br />NOW <br />P <br />BECK: <br />„.. <br />HUT -3 ORIGINAL J"" <br />