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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN , 60�_ East Main Street, Stockton, California 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd UNDERGROUND STORAGE TANK (UST) PRnr.RAM IAI1QP1=rT1nK1 DC0nDT Facility name: �I o, `e Q '�1/ n Designated Operator: Inspection Date: V J 1 1' lam' V Facility address: UST # - s 'Product Facility Cont ct: � Cont Title: Phone: Monitoring Panel: ing system: 2ressurized Overfill prevention: 11 Suction 11 Gravity 11 Mechanical Audible/visual Inspection type: Violations: Routine Monitoring Certification ❑ Installation ❑ Other: ❑ M1-RDetect ❑ M2-RPrev ❑ M-3 Both # Code Section VIOLATION(S) HSC=California Health & Safety Code; CCR=California Code of Regulations V R V=Violation; RV=Re eat Violation V 1 HSC 25284 Permit too erste 2 CCR 2637 Secondary containment test performed /L*) p 3 CCR 2711 b & c Current Unified Program Consolidated Forms on file with EHD(Facility and tank form 4 HSC 25292.2 Certification of financial responsibility and CFO letter 5 CCR 2632 b Monitoring Program(Monitoring & Response Plan is current and approved by the local agency. 6 CCR 2712 i Monitorinq plan is onsite. 7 CCR 2712 b Maintenance & monitoring records M1) 8 CCR 2643 d Daily monitoring of suction piping (pre -January, 1, 1984 9 HSC 25292.1 UST system isoperated to prevent unauthorized release 10 CCR 2632 (c)(2) UST monitoring system is present (M1) 11 CCR 2630 d UST system monitoring equipment is properly located to detect a leak M1) 12 HSC 25291 b UST system monitoring equipment is operational (M1) 13 CCR 2636 (f)(1) Continuous monitoring system for underground piping & UDC is present (M1 14 CCR 2631 a Primary containment is product tight 15 HSC 25291 (a)(2) Secondary containment for UST is tight 16 CCR 2636 (c)(1) All releases in secondary pipingflow to a collection sum 17 HSC 25291 f Line leak detector(s) are installed (M1 18 CCR 2635 (b)(1) Spill container (M2) 19 CCR 2635 (b)(2) Overfill prevention system M2 20 CCR 2636 (a) Conventional suction piping shall have continuous monitoring & 20 containment 21 HSC 25291 (e) Water in 2° containment analyzed & properly disposed of 22 1 CCR 2650 Record! ng/repo rting of unauthorized releases M1) 23 CCR 2715 Designated Operator: a Statement from UST owner; c -e onthl ins ection; m to ee training 24 CCR 2638 a Annual monitoring certification 25 CCR 2638 a Annual line leak detector test (M1 26 HSC 25284.2 Annuals ill containment testing 27 CCR 2636 (f)(4) Annual line tightness test (M1 28 CCR 2661 Repair for tank/piping has had tightness test (M2) 29 CCR 2643 a Biennial tightness test of gravity pipingre-Janus 1, 1984 30 CCR 2643 d Triennial line test for conventional suction piping (pre -January 1, 1984) (M1) 31 HSC 25292.5 Double walls stem located within 1000' of public well-ELD 32 CCR 2661 Permit to repair UST system 33 HSC 25286 a Permit to alter monitoring system 34 HSC 25298 b Permit to temporarily close UST system 35 HSC 25298 c Permit to close UST system 36 HSC 25299 Disabling leak detection devices a 9 f 2 37 HSC 25298 a Illegal abandonment of UST system 38 Other: EHDINTOR: PHONE: / UIC Septic system: ❑ Serves >_20 people/day ❑ Receives other than sanitary waste Other disposal methods: RECEIVED BY: TITLE: &V /Y ❑ Dry wells/French Drains EHD 23-02-002 REV 8/08