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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 Name ,L/ cS gram ID# //0 % <br />Facility Address '7-e'�' 7 S J City S Zip <br />UST: Dual Wall SingleWal OVE FILL: Audible Visual Mechanical <br />PIPING SYSTEM: Dual wallingle wall Suction Pressure--j,!�`Gravity <br />DOES THE LEAK DETECTION SYSTEM meet 23CCR 2636(g) requirements? YES NO_&�--- <br />VIOLATIONS <br />T111T11 <br />i iiL�A tt <br />UST GENERAL REQUIREMENTS <br />Permit to Operate [H&SC 252841 <br />Forms A & B Current LH&SC 25284 c <br />Monitorin Maintenance Records 23CCR 2712 b <br />Financial Responsibility rT4&.qr 91;292.2(a)l <br />monitoring Records Available 23CCR 2712 <br />Monitoring Plan 23CCR 2632(d)(1)] <br />Resnonse Plan r23CCR 2632(d)(2)1 <br />Unauthorized Releases Reported [H&SC 25295] <br />Monitoring Equipment Annual Cert. 23CCR 2630 <br />ver spill on ai.ner <br />Cathodic Protection 23CCR 2635 a 2 A <br />New USTs Monitored Continuously [23CCR 26301 <br />MANUAL INVENTORY RECONCILIATION (MIR) <br />Meters <br />Gauging Stick in 1�8 Inches r23rrR 9646(c!)(1)(T?,)j <br />Monthly Variations Calculated [23CCR 2646(d)] <br />Ex-yaria ir rocs ure Followed L23CCR 2646(e)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 <br />AUTOMATIC TANK GAT ING (ATM <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 />Annuai Ianxn egri y Iest <br />Tanx Uauging J?rocecture kollowecL <br />D;eb4btCL)j- <br />ailv Suction Piping Monitorincr r23CCR ADD.II1 <br />Piping Tightness Test 23CCR 2643 b c d <br />Gravity Piping Tested Every 2 Years [23CCR 2643(e)] <br />Monthly Line Test L23CCR 2643 c 2 <br />AnnuaT <br />TANK REMOVAL <br />Permit to Close or Cease Operation H&SC 25298 <br />Remove2fiosel5pr Tempor y Close 23CCR 2670 ¢� <br />G7 <br />REHS INSPECTION DATE/TYPE: Sa <br />RECEIVED BY • PHONE C Q p��,I1 <br />17 <br />Revised Date 7/15/97 23 CCR UST Regs May 5, 1994 PAGE of—3 <br />PHS 260 (4/98) <br />