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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 Namephl /O v l� rogram ID# <br /> Facility Addres City Zip <br /> UST- Dual Wall Single 11 O RFILL: Audible Visual—Mechanical <br /> PIPING SYSTEM: Dual wallSingle wall Suction Pressure Gravity <br /> DOES THH LEAK DETECTION 1q11-EM meet 23CCR 2636 (g) 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 25284c <br /> Monitorin Maintenance Records 23CCR 2712 b <br /> Monitoring Records Available 23CCR 2712 <br /> Monitoring Plan 23CCR 2632 (d) (1) ] <br /> Resnonse Plan r23CCR 2632 (d) (2) 1 <br /> Unauthorized Releases Re orted [H&SC 252951 <br /> Monitoring Equipment Annua Cert. 123CCR 2630 <br /> Over spill 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 4 <br /> Monthly Variations Calculated [23CCR 2646 (d) ] <br /> Ex-Variation Procedure koilowed L2.3UUR :2b46 (e) j <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 /> a1 y Stick Rea7a-1Hg='1ccRc <br /> AUTO TIC TANK GAUGING fATG) <br /> Monthly ATG Results [23CCR 2643 (b) (1) ] <br /> Annuaiummary Report <br /> MANUAL UST TANK GAUGING (MTG) <br /> Tank Gauging Weekly [23CCR 2645 (b) ] <br /> Annual lankn egri y Test <br /> TanK Gauging roce ure FoIlUwea <br /> PIPING' MONITORING <br /> Daily Suction Pii)incr Monitoring2 R Apip.III <br /> Piping Tightness Test 23CCR 2643 b c d <br /> Grayit Pi in Tested Ever 2 Years [23CCR 2643 (e) ] <br /> Mont y Line Test 23CCR 2643 c2 <br /> Knnuai <br /> TANK REMOVAL <br /> Permit to Close orCease Operation H&SC 25298 <br /> Remove ose Temporar y C ose 23CCR 2670 <br /> REHS INSPECTION DATE/TYPE: �/ n <br /> RECEIVED BY: PHONE: d(�'J}(7` <br /> Revised Date 7/15/97 23 CCR UST Regs May 5, 1994 PAGE / of <br /> PHS 260 (4/98) <br />