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1 <br />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 '�7� G' �i City S zip <br />UST: Dual Wall ingle 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 />UST GENERAL RE UIREMENTS <br />Permit to O erate [H&SC 252841 <br />Forms A& B Current LH&SC 25284(b)(C)l <br />Monit0rinqZMaintenance Records r23CCR 2712 b <br />MonitOrin Records Available 23C2R 2712 <br />Monitorin Plan 23CCR 2632 d)(1) <br />Response Plan r23rc-g 26-i2(d)(2)1 <br />Unauthorized Releases Re orted [H&SC 252951 <br />Monitoring Equipment Annua Cert. 23CCR 2630 <br />Over s i on ainer <br />Cathodic Protection 23CCR 2635 a 2 A <br />New USTs Monitored Continuously [23CCR 2630] <br />MANUAL INVENTORY RECONCILIATION (MIR) <br />Meters Calibrated r23CCR 9.646(i)l <br />Monthly Variations Calculated [23CCR 2646(d)] <br />Ex -Variation roce ure o owe e <br />STATISTICAL 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 ReacLing c <br />AUTOMATIC TANK GAUGING (ATQ) <br />Monthly ATG Results [23CCR 2643(b)(1)] <br />Annual Summary Report <br />MANUAL QST TANK GAUGING (MTG) <br />Tank Gauging Weekly [23CCR 2645(b)] <br />Annual an n egri y lest <br />an au ing Proce0ure kollowea <br />PIPING MONITORING <br />Daily Suction Piping Monitoring f23CCR App.1 <br />Piping Tightness Test 23CCR 2643 b c d <br />Gravit Pi in Tested Ever 2 Years [23CCR2643(e)] <br />Mont y Line Test 23CCR 2643 c 2 <br />TANK REMOVAL <br />Permit to Close or Cease Operation H&SC 25298 <br />Removed,,osed or Temporar y Closed [23CCR 2670J <br />REHS� A INSPECTION DATE/TYPE:' <br />RECEIVED BY: PHONE: <br />Revised Date 7/15/97 23 CCR UST Regs May 5, 1994 PAGE / of,5 <br />PHS 260 (4/98) —r-- <br />