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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 />Facy�UND GRO STORAGE TANK (UST) /PROGRAM INSPECTION REPORT <br />�ti��iGiY' (( S / /F ram ID# <br />Facility Address 1 y, City s, Zips <br />UST: Dual Wall _Single all OVERFILL: Audible_X isual Mechanic` <br />PIPING SYSTEM: Dual wall, Single wall Suction Pressure Gravity <br />DOES THE LEAK DETECTION SYSTEM meet 23CCR 2636(8) requirements?"YES NO <br />VIOLATIONS <br />UST GENERAL REQUIREMENTS <br />Permit to Operate [H&SC 25284] <br />Forms A & B Current H&SC 25 84 c <br />monitoring/Maintenance Records 23CCR 2712 b <br />Financial Responsibility rH&SC 2c;n92_2(a)1 <br />Monitoring Records Available 23CCR 2712 <br />Monitoring Plan 23CCR 2632(d)(1)] <br />Resnonse Plan r2lrCR 2632(d)(2)1 <br />Unauthorized Releases Reported [H&SC 252951 <br />Monitoring Equipment Annual Cert. 23CCR 2630 <br />ver s i1i Container <br />Cathodic Protection 23CCR 2635 a 2 A <br />New USTs Monitored Continuously [23CCR 26301 <br />MANUAL INVENTORY RECONCILIATION (MIR) <br />-Meters Calibrated r23ccg 2646(i)i <br />Gauging Stick in 1)8 Inches r23CCR 2646(c)(I)(R)i <br />Monthly Variations Calculated [23CCR 2646(d)] <br />Ex -Variation Procedure Foilowed L23CCR 2646(e)j <br />STATISTI:AL INVENTORY RECONCILIATION (SIR) <br />Inconclusive Procedure Followed [23CCR 2646.1(d)3 <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 GAUGING (ATO) <br />Monthly ATG Results [23CCR 2643(b)(1)] <br />Annuai AxU summary Report <br />MANUAL UST TANK GAUGING (MTG) <br />Tank Gauging Weekly [23CCR 2645(b)] <br />Annual Tankn egri y Test <br />7anx Gaugingroce ure PoI.Lowed <br />PIPING MONTTORTNa <br />Daily Suction Piping monitoring r23CCR Avy.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 />Axalual <br />�x <br />TANK REMOVAL <br />Permit to Close or Cease Operation H&SC 25298 <br />Remov C ose or Temporar y C ose 23CCR 2 70 <br />xEkis Z :INSPECTION DATE TYPE: 11 <br />RECEIVED BY: r. PHONE: <br />Revised Date 7/15/97 23 CCR UST Regs May 5, 1994 PAGE of <br />PHS 260 (4/98) <br />