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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 TANK PROGRAM OFFICIAL INSPECTION REPORT <br /> Facility Name �, Facility ID# <br /> Facility Address City Zip <br /> Facility Phone # Facility Contact <br /> Inspection Date: Inspection Type: a;2_ <br /> UST: Dual Wall_ Single Wall OVERFILL: Audible_ Visualechanica <br /> Vil_ <br /> UST Monitoring Alternative UST Contents a. <br /> PIPING SYSTEM: Dual Wall_XSingle Wal l_Suct ion--X—Pres sure Gravit <br /> Does the leak detection system shut off the pump automatically? YES_ NO <br /> VIOLATIONS <br /> TANK # <br /> II3T GENERAL REQUIREMENTS 1A.An <br /> Permit to Operate [H&S 25284] <br /> Forms A & B current c <br /> Monitoring/Maintenance Records <br /> Financial Responsibility [H&S 25292.2 (a) ] <br /> monitoring Records Available <br /> Monitoring an <br /> Response Plan L23CCR 2632 (d) (2) ] <br /> Unauthorized Releases Reported &S 272-975 -- <br /> Monitoring <br /> 5 95Monitoring Equipment Annual Test L23CCR 2630777 <br /> Over spill on alner <br /> Permitted UST Repairs 23CCR 2661 <br /> Permitted Upgrades [23CCR 2660] <br /> Cathodic ro ec ion a <br /> MANUAL INVENTORY RECONCILIATION MIR <br /> UST Integrity Test [23CCR 2643 .1] <br /> Annual MIR Report 23CCR 2646 <br /> Meters Calibrated [23CCR 2646 (e) (4) ] <br /> Daily tic res in CR 44 c 1 <br /> Gauging Stick in 1/8 inches [23CCR 2646 (c) (1) (E) ] <br /> STATISTICAL INVENTORY RECONCILIATION SIR <br /> Excessive Variation Reported 23CCR 2646.1 (d) <br /> UST Integrity es every two ears <br /> Annual SIR Report L23CCR 2646.1 7 <br /> a"y StiCK Reading L23CUR 2b4b kC) <br /> AUTOMATIC TANK GAUGING ATG <br /> Monthl ATG Results [3CCR 2643 (b) (1) ] <br /> Annua ATG Summary Report L23CCR 2712 (b) (2) ] <br /> MANUAL UST TANK GAUGINGMT <br /> Tank Gau in Weekl [23CCR 2645 (b) ] <br /> Annua Tan Integrity Test 23CCR 2645 <br /> PIPING MONITORING <br /> iTally Suction Piping Monitoring [23CCR APP.III <br /> Piping Tightness Test [23CCR 2643 (b) , (c) , (d) ] <br /> Gravity Piping es a every 2 years e <br /> Monthly Line Test L23CCR 2643 c 2 <br /> Annual eak Detector test L23CCR App.lV(1) (d) j <br /> SYSTEM STATUS: Major Violations No Violations <br /> COMMENTS: G J1-Z_ <br /> REHS: f r RECEIVED HY n <br /> TITLE:� I'Yy PHONE: 8 DAT : <br /> Revised Date 1/29/97 2 CCR UST Regs May 5, 1994 <br />