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UNDERGROI#ANK PROGRAM OFFICIAL INS <br /> IC ION REPORT <br /> AN JOAQUIN HEALTH DISTR <br /> 1601 E. HAZELTON AVE. <br /> COUNTY NAME STOCKTON, CA 95205 COUNTY # 3� <br /> PHONE NO. 468-3423 <br /> SITE NAME: INSPECTION DATE: �y� <br /> SITE ADDRESS: _ CITY/STATE/ZIP <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK TANK TANK TANK <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER COMPUTER <br /> NUMBER NUMBER NUMBER NUMBER <br /> TYPE OF INSPECTION SITE COMPUTER# # <br /> PER (07-x/ PER# ��67-U <br /> p / _ /� R# lt67 PER# <br /> 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 8 _ — <br /> APPROVED MONITORING SYSTEM 9 10 <br /> MONITORING SYSTEM 11 12 <br /> APPROVED MONITOR FREQUENCY 13 14 <br /> MONITORING RECORDS MAINTAINED 15 16 <br /> ACCESS CASING SECURED 17 18 1 <br /> PIPING 19 20 5 <br /> INVENTORY RECONCILIATION 21 22 O <br /> TANK GAUGING 23 24ry <br /> � <br /> APPROVED RESPONSE PLAN 25 26 <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 28 < ?7 <br /> SAMPLING 29 30 <br /> APPROVED TANK REPAIRS 31 32 <br /> UNAUTHORIZED RELEASES REPORTED 33 34 _ <br /> SAFETY HAZARD <br /> CONDITIONS ABATED 37 <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL 38 J43 <br /> FLAMMABLE VAPORS REMOVED 40ACCESS LOCATIONS SEALED 41 POWER DISCONNECTED OWNER/OPERATOR MONITORING 44 <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 µ <br /> SAMPLING 53 54 <br /> IMPROPER ABANDONMENT 55 56 <br /> T ARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONE) FOLLOWS: i <br /> MAJOR 57 MINOR 58 NO 59 S d h cs <br /> VIOL. LiVIOL. LJVIOL. <br /> OFFICE: INSP: RECE V D BY: <br /> ,6�, <br /> TITLE: PHONE: 1�1-3/A RECK: <br /> HUT-3 ORIGINAL / �� �� °I�tti'ZH'�l1 5/88 0M <br />