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PUBLIC HEALTH SERVICES SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 E. Weber Ave. , Third Floor, Stockton, CA 95202 <br /> (209) 468-3420 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM INSPECTION REPORT <br /> Facility Name Program ID# <br /> Facility Address City Zip <br /> UST: Dual Wall Single Wall OVERFILL: Audible Visual_Mechanical <br /> PIPING SYSTEM: Dual wall Single wall Suction Pressure Gravity <br /> DOES THE LEAK DETECTION SYSTEM meet 23CCR 2636 (8) requirements? YES NO <br /> VIOLATIONS <br /> TANK # <br /> UST GENERAL REQUIREMENTS <br /> Permit to Operate [H&SC 252841 <br /> Forms A & B Current H&SC 25284 c <br /> monitoring/Maintenance Records 23CCR 2712 b <br /> Monitoring Records Available 23CCR 2712 <br /> Monitoring Plan [23CCR 2632 (d) (1) ] <br /> Resiponse Plan r23CCR 2632 (d) (2) 1 <br /> Unauthorized Releases Reported [H&SC 25295] <br /> Monitoring Equipment Annual Cert. 23CCR 2630 <br /> over spiii Container <br /> Permitted UST R2nairs r2-4('('R 26611 <br /> Cathodic Protection 23CCR 2635 a 2 A <br /> New USTs Monitored Continuously [23CCR 2630] <br /> MANUAL INVENTORY RECONCILIATION (MIR) <br /> UST Integrity Test 123CCR 2e43 .11 <br /> Meters rated F23CCR 2 4 i <br /> nai lv qt-J r-k Rearling [?V= ?r,4F (r) (I ) l <br /> Monthly Variations Calculated [23CCR 2646 (d) ] <br /> Ex-variation Procedure Foiiowect L23CCR—,T=(e) j <br /> STA 'ISTICAL INVENTORY RECONCILIATION (SIR) <br /> Inconclusive Procedure Followed [23CCR 2646 .1 (d) ] <br /> UST Integrity Test Every Two Years 23CCR 2646 .1 <br /> Annual SIR Report [23CCR 2646 .1 (j) ] <br /> ai y Stick Reading c <br /> AUTOMATIC TANK GAUGING (ATG) <br /> Monthly ATG Results [23CCR 2643 (b) (1) ] <br /> Annuai ATG Summary Report <br /> MANUAL UST TANK GAUGING (MTG) <br /> Tank Gauging Weekly [23CCR 2645 (b) ] <br /> nua an n egri y lest L2T77R7=n (rD) j <br /> Tank, auging Procecture o Lowe <br /> Daily Suction Piping monitoring 23 CR Aipp. IV <br /> Piping Tightness Test 23CCR 2643 b c d <br /> Gravity Piping Tested Every 2 Years [23CCR 2643 (e) ] <br /> Monthly Line Test 23CCR 2643 c 2 <br /> Annuai LeakDerector es <br /> TANK REMOVAL <br /> Permit to Close or Cease Operation H&SC 25298 <br /> Removed, Closed or Temporar y C ose 23CCR 2670 <br /> REHS INSPECTION DATE/TYPE: <br /> RECEIVED BY: PHONE: <br /> Revised Date 7/15/97 23 CCR UST Regs May 5, 1994 PAGE of <br /> PHS 260 (4/98) <br />