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COUNTY NAME <br />UNDERGROW TANK PROGRAM OFFICIAL INS CTION REPORT <br />SAN JOAQUIN HEALTH DISTRI <br />1601 E. HAZELTON AVE. <br />STOCKTON, CA 95205 COUNTY # <br />PHONE NO. 468-3423 <br />SITE NAME: S <br />5 <br />INSPECTION DATE: <br />SITE ADDRESS: <br />CITY/STATE/ZIP <br />r• <br />CHANGES SITE/OWNER/PERMIT? <br />YES <br />NO <br />TANK <br />TANK TANK TANK <br />FORM A AND/OR B SUBMITTED? <br />COMPUTER <br />COMPUTER COMPUTER COMPUTER <br />NUMBER <br />NUMBER NUMBER NUMBER <br />TYPE OF INSPECTION SITE COMPUTER # <br />® <br />/Y3 <br />PER # <br />PER # PER # PER # <br />EXP. DATE <br />EXP. DATE EXP. DATE EXP. DATE <br />OPERATIONAL TANK <br />TANK CONTENTS <br />MAJOR I 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-F// <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 />Pv-� <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 />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 />POWER DISCONNECTED <br />43 <br />OWNER/OPERATOR MONITORING <br />44 <br />45 <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 />w <br />SAMPLING <br />53 <br />54 <br />IMPROPER ABANDONMENT 55 56 <br />THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST MARK ONE) FOLLOWS: /Seer 1�—� r.�, 12 .. <br />MAJOR 57 MINOR 58 NO 59 <br />VIOL. VIOL. ❑ VIOL. ❑ <br />OFFICE: INSP: CEIVED BY: <br />TITLE: P ONE. <br />cK: <br />HUT —3 ORIGINAL 5/88 0� <br />