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UNDERGROU�ANK PROGRAM OFFICIAL INS ON REPORT <br /> AN JOAQUIN HEALTH DISTRIC <br /> 1601 E. HAZELTON AVE. <br /> COUNTY NAME STOCKTON, CA 95205 COUNTY # <br /> PHONE NO,. 44668-3423 <br /> SITE NAME: INSPECTION DATE: �� O <br /> SITE ADDRESS <br /> Q //j / CITY/STATE/ZIP <br /> CHANGES SITE/OWNER/PERMIT? YES ! NO TANK �� TANK Z, TANK �3 O TANK o S <br /> FORM A AND/OR B SUBMITTED? COMPUTER COMPUTER COMPUTER I COMPUTER <br /> TYPE.OF INSPECTION SITE CO TER# NUMBER NUMBER NUMBER ' / UMBER <br /> PER# PER# PER 4/" R# <br /> ��. / / 7y 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 <br /> PIPING 19 20 <br /> INVENTORY RECONCILIATION 21 22 <br /> TANK GAUGING 23 24 <br /> APPROVED RESPONSE PLAN 25 26 <br /> UNAUTHORIZED RELEASE OCCURRENCE 27 28 <br /> SAMPLING 29 130 <br /> APPROVED TANK REPAIRS 31 32 <br /> UNAUTHORIZED RELEASES REPORTED 33 34 _. <br /> SAFETY HAZARD 35 36 <br /> CONDITIONS ABATED 37 �� � � <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL 38 39 <br /> FLAMMABLE VAPORS REMOVED 40 <br /> ACCESS LOCATIONS SEALED 41 42 w. <br /> POWER DISCONNECTED 43 <br /> OWNER/OPERATOR MONITORING 44 45 <br /> PERMANENT TANK CLOSURE <br /> im <br /> REMOVAL OF RESIDUAL MATERIALS r51 <br /> 47 <br /> PIPING 49 <br /> FLAMMABLE VAPORS REMOVED <br /> UNAUTHORIZED RELEASE 52SAMPLING 54 <br /> IMPROPER ABANDONMENT 155 156 <br /> THE MARKErux,EMS RJEP ESENT VIOLATI NS A D MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MARK ONE) FOLLOWS: <br /> 57 IIII <br /> MAJOR MINOR E NO 5MJ <br /> VIOL. VIOL. VIOL.LTJ <br /> OFFICE: ' INSP"9 RECEIV D BY: <br /> TITL[i PON : ECK: <br /> HUT-3 ORIGINAL 5/88 <br />