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PUBLIC HEALTH SERVICES SAN <br />ENVIRONMENTAL HEALTH <br />304 E. Weber Ave., Third Floor, <br />(209) 468-3420 <br />Ll <br />JOAQUIN COUNTY <br />DIVISION <br />Stockton, CA 95202 <br />UNDERGROUND STORAGE TANK (UST) PROGRAM INSPECTION REPORT <br />Facility Name CL ]�& ®4_ ID# <br />Facility Address City ip <br />UST: Dual Wall Single Wall O RFILL: Audible - VIZ--i'—anical <br />PIPING SYSTEM: Dual wall Y <br />Single wall ;Suction "5XPressure Gravity <br />DOES THE LEAK DETECTION SYSTEM meet 23CCR 2636(8) re—(Xirements? YESNO <br />VIOLATIONS <br />M'AlkTW -U <br />UST GENERAL REQUIREMENTS <br />2�wf-mif-to 42-erafie- <br />_7 <br />H&SC 25284J <br />-ty <br />New USTs Monitored Continuously [23CCR 263 0] <br />MANUAL INVENTORY RECONCILIATION (MIR) <br />E"UMSM <br />Monthly variations Calculated [23CCR 2646(d)] <br />R <br />Annual SIR Report (23CCR 2646.1(j)] <br />Monthly ATG Results (23CCR 2643(b)(1)1__ <br />rnMANUAL UST TANK GAUGING (KrG) <br />VC-•—TOT-Te- <br />------Iy —Line Tes-tT23CCR 2643(c)(2)] <br />Month <br />TANK REMOVAL <br />L=:0!1WA101 ARM% <br />REHS 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 (4/98) <br />