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a,I <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 rogram <br /> Facility Address , ',a(> - City C zip 4�� � <br /> UST: Dual Wall Single Wall - OVERFIL • Audible Vie al_Mechanical <br /> PIPING SYSTEM: Dual wall Single wallSuction_ _Pressure Gravity <br /> DOES THE L8A8 DHTSCTION SYSTEM meet 23CCR 2636 (g) requirements? YES_NO]� <br /> TANK <br /> ±YZIOLATIONS <br /> # <br /> UST GENERAL R8 UIR8MENTS <br /> Permit to 0 erate [H&SC 252841 <br /> Forms A & B Current IM&SC 25284 (b) (c) i <br /> Monitoring/Maintenance Records f23CCR 2712 (b) ] <br /> Monitorin Records Available 23CCR 2712 <br /> Monitorin Plan 23CCR 2632 d 1 <br /> Unauthorized Releases Re orted [H&SC 25295] <br /> Monitoring Equipment Annus ert. E9 :I:: <br /> L23CCR 2630 <br /> Over spill on ainer �!I <br /> Cathodic Protection r23CCR 2635 a 2 A <br /> New USTs Monitored Continuously [23CCR 2630] <br /> MANUAL INVENTORY RECONCILIATION (MIR) <br /> Meters Calibrated f23CCR 2646W1 <br /> Monthly Variations Calculated [23CCR 2646 (d) ] <br /> Ex-variation Proceaure Followed L;&-iL:L:K ;4646 (_eTT <br /> STATISTICAL INVZ24TORY RECONCILIATION (9191 <br /> Inconclusive Procedure Followed [23CCR 2646.1 d) <br /> UST Inte rit Test Eve Two Years 23CCR 2646.1 <br /> Annual SIR Report [23CCR 2646.1(j) ] <br /> ai y is ea ing c <br /> Monthly ATG Results [23CCR 2643 (b) (1) ] <br /> Annual Summary Report <br /> MANUAL UST TANR GAUGING (MTG) <br /> Tank Gauging Weekly [23CCR 2645(b) ] <br /> Annual anx integrity e <br /> lanic Gaugingr ce ure Y0110weo <br /> PIPING MONITORING <br /> Piping Tightness Test r23CCR 2643 b c d <br /> Gravit Pi in Tested Eve 2 Years [23CCR 2643 (e) ] <br /> Mont y Line Test 23CCR 2643 c 2 <br /> TANK REMOVAL <br /> Permit to Close or Cease eration H&SC 25298 <br /> Removed, ose or Temporarly closea L23CCR 26701 <br /> REHS INSPECTION DATE/TYPE: — 9 <br /> RECEIVED BY: PHONE: <br /> Revised Date 7/15/97 23 CCR UST Regs May 5, 1994 PAGE__Lof3�— <br /> PNS 280 (4/'88) <br />