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D <br />PUBLIC HEALTH SERVICES SAN <br />ENVIRONMENTAL HEALTH <br />304 E. Weber Ave., Third Floor, <br />(209) 468-3420 <br />U <br />JOAQUIN COUNTY <br />DIVISION <br />Stockton, CA 95202 <br />UNDERGROUND STORAGE TANK (UST) PROGRAM INSPECTION REPORT <br />Facility Name l 1 "ROM Program ID# <br />�' <br />Facility Address � e- City zip &) <br />(0 <br />UST: Dual Wall Single wall OVERFILL: Audible Visual Mechanical <br />PIPING SYSTEM: Dual wall V"Single wall Suction Pressure:j�Gravity <br />DOES THE LEAK DETECTION SYSTEM meet 23CCR 2636(8) requirements? YES NO--v-;w"- <br />VIOLATIONS <br />1li191\ {� <br />UST GENERAL REQUIREMENTS <br />Permit to Operate [H&SC 25284] <br />Forms A & B Current H&SC 25284 c <br />Monitorin Maintenance Records 23CCR 2712 b <br />Monitoring Records Available 23CCR 2712 <br />Monitoring Plan 23CCR 2632(d)(1)] <br />Response Plan r23CCR 2632(d)(2)1 <br />Unauthorized Releases Reported [H&SC 25295] <br />Monitoring Equipment Annual Cert. 237CR 2630 <br />ver s i Container L23CCR 263.5 (b) J <br />Cathodic Protection 23CCR 2635 a 2 A <br />New USTs Monitored Continuously [23CCR 26301 <br />MANUAL INVENTORY RECONCILIATION (MIR) <br />Meters Calibr�ted 2 i <br />Gauging Stick in 1�8 Inches r2'ArrR 5)646(c)(1)(F)l <br />Monthly Variations Calculated [23CCR 2646(d)] <br />x- aria l.on roce ure FoiIowecL L23CC-R 2b4b (e) <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 />ai yis ea ing c <br />AUTO TIC! TANK GAUGING (ATO) <br />Monthly ATG Results [23CCR 2643(b)(1)] <br />Annual AXG summary Report <br />MANUAL UST TANK GAUGING (MTG) <br />Tank Gauging Weekly [23CCR 2645(b)] <br />Annual Iankn egri y rest <br />rank GaugIng Proceaure FolloweC <br />Daily Suction Piping Monitorincf r23CCR App.III <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 />Annual r <br />TANK REMOVAL <br />Permit to Close or Cease Operation H&SC 25298 <br />Removed, CT-osed or Temporar y Closed 23CCR 2670 <br />HS L� NSPECTION DATE/TYPE := U - <br />RECEIVED BY: PHONE: <br />Revised Date 7/15/97 23 CCR UST Regs May 5, 1994 PAGE /2- of <br />PHS 260 (4/98) <br />