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iN <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 Address ? ,�07 �c City S Zip <br /> UST: Dual Wall Single Wall OVERFILL: dible Visual_Mechanical 4 <br /> PIPING SYSTEM: Dual wall Single wall / Suction Pressure Gravity <br /> DOES TH9 LEAK DETECTION SYSTEM meet 23CCR 2636 (.8.) requirements? YES - NO <br /> VIOLATIONS <br /> TANK # <br /> UST GENERAL REQUIREMENTS <br /> Permit to Operate [H&SC 25284) <br /> Forms A & B Current H&SC 25284 : c <br /> Monitoring/maintenance Records F23.CCR 2712 (b) ] <br /> Monitoring Records Available 23CCR 2712 <br /> Monitoring Plan 23CCR 2632 (d) (1) ]; <br /> Resnonqe Plan r2aCCR 2632 (d) (2) 1 <br /> Unauthorized Releases Reported [H&'SC 252951 <br /> Monitoring Equipment Annual Cert. 123CCRr2630 <br /> Over spill on ainer <br /> Cathodic Protection 123CCR 2635 a 2 A <br /> New USTs Monitored Continuously [23CCR 26301 <br /> MANUAL INVENTORY RECONCILIATION (MIR) <br /> Meters Calibrated F23CCR 4 <br />` Monthly Variations Calculated [23CCR 2646 (d) ] <br /> Ex-Variation Proceaure Followed L2.3CUR 2b4b (e) j <br /> STATL-LTjLU INVENTORY RECONCILIATION (SIR) <br /> Inconclusive Procedure Followed [23CCR 2646.1 (d) ] <br /> UST Inte2rity Test Every Two Years 23CCR 2646.1 <br /> Annual SIR Report [23CCR 2646 .1 (j)] <br /> Daily Stick Reading: L23UURc <br /> AUTOMATIC TANK GAUGING (ATQ) <br /> Monthly ATG Results [23CCR 2643 (b);(1) 1 <br /> Annual Summary Report <br /> MANUAL UST TANK GAUGING (MTG) <br /> Tank Gauging Weekly [23CCR 2645 (b) ] <br /> Annual an n egri y Iest <br /> Tank auging Proceaure Fol-Lowed <br /> NG M0NTTnT?TMr_ <br /> Daily Suction PipingMnitorincr r23gQR Aby, lyi <br />` <br /> Piping Tightness Test 23CCR 2643 b c d <br /> Gravity Piping Tested Every 2 Years [23CCR 2643 (e) ] <br /> Monthly Line Test 23CCR 2643 c 2 <br /> lAnnual Lt=ax L)ete7Eor <br /> I" <br /> TANK REMOVAL <br /> Permit to Close or Cease OperationH&SC 25298 <br /> E Remove ose or Temporar y Closed 23CCR 2670 <br /> F <br /> REHS L' INSPECTION DATE/TYPE: 7 ' <br /> RECEIVED-BY: PHONE: <br /> Revised Date 7/15/9.7 23 CCR UST Regs May 5, 1994 PAGE�of, <br />( PHS 260 (4/98) <br /> L <br />