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f- <br /> ' <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 Nameprogram ID# <br /> Facility Addres J /f�<</ City Zip <br /> UST: Dual WallSingle11 OVERFILL: Audible Visual Mechanical �; <br /> PIPING SYSTEM: Dual wall n Single wall Suction Pressure Gravity <br /> DOES THE LEAK DETECTION SYSTEM meet 23CCR 2636 (g) requirements? YES NO-� <br /> VIOLATIONS <br /> TANK # <br /> UST GENERAL R8 UIRBMSNTS <br /> Permit to O erste [H&SC 252841 <br /> Forms A & B urrent JH&SC 252 4 c <br /> Monitoring/maintenance Records 23CCR 2712 b <br /> Financial Responsibility fH&SC 252922 (a) l <br /> Monitoring Records Available 123CCR 2712 <br /> Monitoring Plan 23CCR 2632 (d) (1) <br /> Response Plan r23CCR 2632 (d) (2) 1 <br /> Unauthorized Releases Re orted [H&SC 252951 <br /> Monitoring Equipment Annus Cert. L23CCR 2630 <br /> Over spill on ainer <br /> Cathodic Protection 123CCR 2635 a 2 A <br /> New USTs Monitored Continuously [23CCR 2630] <br /> MANUAL INVENTORY RECONCILIATION (MIR) <br /> Meters Calibrated 2 <br /> Monthly Variations Calculated [23CCR 2646 (d) ] <br /> Ex-Variation Procedure Foiiowee) j <br /> _IIA=ICAL 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 Reading L23CCR 2747-7c! <br /> .A=OMATIC TANK GAUGING (ATr) <br /> Monthly ATG Results [23CCR 2643 (b) (1) ) <br /> Annuai AiG Summary Report <br /> MANUAL UST TANK GAUGING (MTG) <br /> Tank Gauging Weekly [23CCR 2645 (b) ] <br /> Annuai. ranxn egri y rest <br /> a'anK Uauging roce ure o owe <br /> PING MONTTORTNa <br /> Daily Suction Piping r'n A1D.111 <br /> Piping Tightness Test 23CCR 2643 b c d <br /> Gravit Pi in Tested Ever 2 Years [23CCR- 2643 (e) ] <br /> Mont y Line Test 23CCR 2643 c 2 <br /> Detector <br /> TANK REMOVAL <br /> Permit to Close or Cease Operation H&SC 25298 <br /> Removed, ciosea or Temporar y C ose 2 CR 2670 <br /> REHS -+- - INSPECTION DATE/TYPE: c... <br /> RECEIVED BY: /;, PHONE: - <br /> Revised Date 7/15/97 23 CCR UST Regs May 5, 1994 PAGE I of "r <br /> PHS 280 (4/98) <br />