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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 /> UST GENERAL REQUIREMENTS TANK # <br /> Permit to O erate [H&SC 252841 <br /> Forms A & B Current LH&SC 2 4 c <br /> Monitoring/Maintenance Records r23CCR 2712 b <br /> Monitoring Records Available r23CCR 2712 <br /> Monitoring Plan 23CCR 2632 (d) (1) ] <br /> Response Plan r23CCR 2612 (8) (2) 1 <br /> Unauthorized Releases Re orted [H&SC 252951 <br /> Monitoring Equipment Annua Cert. 23CCR 2630 <br /> r <br /> Over sniii Container [23CCR 263b (b) ] <br /> Cathodic Protection 23CCR 2635 a 2 A <br /> New USTS Monitored Continuously [23CCR 26301 <br /> MANUAL INVENTORY RECONCILIATION (MIR) <br /> UST Tntparity Test 121rCR 2641 11 <br /> Meters Calibrated r23CCR 2646 (i) l <br /> Monthly variations Calculated [23CCR 2646 (d) ] <br /> Ex-variation erocedure Foliowee) j <br /> _a=STICAL INVENTORY RECONCILIATION (Sig) <br /> Inconclusive Procedure Followed [23CCR 2646.1 (d) ] <br /> UST Integrity Test Ever Two Years 23CCR 2646.1 <br /> Annual SIR Report [23CCR 2646.1 (j) ] <br /> ai y Stick Reaaing c <br /> AUTOMATIC TANK GAUGING (ATG) <br /> Monthly ATG Results [23CCR 2643 (b) (1) ] <br /> Annuai ATO Summary Report <br /> MANUAL UST TANK GAUGING (MTG) <br /> Tank Gauging Weekly [23CCR 2645 (b) ] <br /> Annua-Lan n egri y lest <br /> 'I'ank Gaugxng -ProcecLure kollowect <br /> PIPING MONITORING <br /> Daily Suction Eiuinq M <br /> Piping Tightness Test r23CCR 2643 b c d <br /> Grayit Pi in Tested Ever 2 Years [23CCR 2643 (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, Closeor Temporar y C ose 23C R 2 70 <br /> REHS INSPECTION DATE/TYPE: <br /> RECEIVED BY: PHONE: <br /> Revised Date 7/15/97 23 CCR UST Regs May 5, 1994 PAGE_,L_of_ <br /> PHS 260 (4/96) <br />