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s <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 Name /)`2^( - O Program ID# <br /> Facility Address _ - ` 2Ary City S ti Zip <br /> UST: Dual Wall Single Wa OVERFILL: Audible Visual Mec anical <br /> PIPING SYSTEM: Dual wall - single wall Suction_Pressure Gravity <br /> DOES THE LEAK DETECTION YSTEM meet 23CCR 2636 (8) requirements? YES NO <br /> VIOLATIONS <br /> UST GENERAL REQUIREMENTS TANK # <br /> Permit to 0112 <br /> erate [H&SC 252841 <br /> Forms A & B Current LH&SC 25284 c <br /> Monitorin Maintenance Records f23CCR 2712 b <br /> Monitoring Records Available 23CCR 2712 <br /> monitoring Plan 23CCR 2632 (d) (1) <br /> RpAnonse Plan [23( CR 2632 (d) (2) 1 <br /> Unauthorized Releases Re ored [H&SC 25295] <br /> Monitoring Equipment AnnuatCert. 23CCR 2630 <br /> Over s i on ainer <br /> PPrmit-i-afj UST Repairs r2'4rf'R 2.6911 <br /> Cathodic Protection f23CCR 2635 (a) 2 A <br /> New USTs Monitored Continuously [23CCR 2630] <br /> MANUAL INVENTORY RECONCILIATION (MIR) <br /> Meters Calibrgted [23CCR 2646 (i) l <br /> Monthly Variations Calculated [23CCR 2646 (d) ] <br /> Ex-variation roce ure o owe ETT— <br /> STATISTICAL <br /> Inconclusive Procedure Followed [23CCR 2646.1 (d) ] <br /> UST Inte rit Test Ever Two Years 23CCR 2646.1 <br /> Annual SIR Report [23CCR 2646.1 (j) ] <br /> ai y Stick Reading c <br /> AUTOMATIC! TANK GAUGING (ATQ) <br /> Monthly ATG Results [23CCR 2643 (b) (1) ] <br /> Annuai ATG Summary-17e—pOrE <br /> MANUAL UST TANK GAUGING (MTG) <br /> Tank Gauging Weekly [23CCR 2645 (b) ] <br /> Annual an n egri y rest <br /> uanK Uauging Proceaure Foilowea <br /> Daily Suction Piping Monitoring 2 I <br /> Piping Tightness Test r23CCR 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 H&SC 25296 <br /> Removed, Closed or Temporar y Ciosed L23CCR 2670 <br /> REHSNS C N DATE/TYPE: I <br /> RECEIVED BY,/ <br /> PHONE: -�A <br /> Revised Date 7/15/97 23 CCR UST Regs May 5, 1994 PAGE I of17 <br /> PHS 260 (4/98) T-' <br />