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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 (VST) PROGRAM INSPECTION REPORT <br /> Facility Name / �- r.�( ( Program ID# <br /> Facility Address City '' Zip <br /> UST: Dual Wa11J�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 (g) requirements? YES NO i <br /> VIOLATIONS 7 <br /> TANK # <br /> UST GENERAL REQUIREMENTS <br /> Permit to Operate [H&SC 25284] - <br /> forms A & B Current [H&SC 25 4 c <br /> Monitoring/maintenance Records 23CCR 2712 b <br /> Monitoring Records Available 23CCR 2712 <br /> Monitoring Plan 23CCR 2632 (d) (1) ] <br /> Response Plan [23CCR 2632 (d) (2) 1 <br /> Unauthorized Releases Re orted [H&SC 252951 <br /> Monitoring Equipment Annua Cert. L23CCR 2630 <br /> Over spill on ainer L23CUR 2635 (b) ] <br /> Cathodic Protection 123CCR 2635 a 2 A <br /> New USTs Monitored Continuously [23CCR 26301 <br /> MANUAL INVENTORY RECONCILIATION (MIR) <br /> Meters Calibrated f23CCR 2646 (i) l <br /> Monthly Variations Calculated [23CCR 2646 (d) ] <br /> Ex-Variation Procedure Followee) j <br /> -STATISTICAL 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 /> Daily Stick Reading c-&9ZQjMj1C TANK GAUGING (ATO) ; <br /> Monthly ATG Results [23CCR 2643 (b) (1) ] <br /> Annual Summary Report <br /> MANUAL UST TANK GAUGING (MTG) <br /> Tank Gauging Weekly [23CCR 2645 (b) ] <br /> Annual Uanxn egri y lest <br /> aank GaugingProcedure iollowed <br /> —21PTNG MONITORING <br /> Daily Suction Pipincr monitoring R AnD.II1 <br /> - <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 /> TANK REMOVAL <br /> Permit to Close or Cease Operation LH&SC 25298 <br /> Remove � Closed or Temporar y Closed 2 R 2670 <br /> REHSJ% INSPECTION DATE/TYPE: <br /> RECEIVED BY: PHONE: <br /> Revised Date 7/15/97 23 CCR UST Regs May 5, 1994 PAGE of / <br /> PHS 260 (4,S8) <br />