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PUBLIL 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 Proaram ID# <br />Facility Address —A&I City Go/� f zip <br />UST: Dual Wall Single Wall OVERFILL: Audible Visual Mechanical <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 />TT 1Tv u <br />UST GENERAL REQUIREMENTS °f <br />Permit to Operate [H&SC 25284] <br />Forms A & B Current H&SC 25284 c <br />Monitoring/Maintenance Records 23CCR 2712(b)] <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 Annua Cert. 23CCR 2630 <br />Over spiii Container <br />Cathodic Protection 23CCR 2635 a 2 A <br />New USTs Monitored Continuously [23CCR 2630] <br />MANUAL INVENTORY RECONCILIATION (MIR) <br />Meters li ated F23CCR 4 i <br />Monthly Variations Calculated [23CCR 2646(d)] <br />EX -Variation Proceaure ollowed L23CUR 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 />ai y Stick Reading c <br />Monthly ATG Results [23CCR 2643(b)(1)] <br />Annuai ATU summary Report <br />MANUAL UST TANK GAUGING (MTG) <br />Tank Gauging Weekly [23CCR 2645(b)] <br />nuai 'rank integrity iest <br />'rank Gauging Procecture FoilowecL <br />PIPING MONITORING I <br />Daily Suction Piping Monitoring F2 CR Aipp.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 />Annuai LeaKe s <br />TANK REMOVAL <br />Permit to Close or Cease Operation H&SC 25298 <br />Removed, Closed or Temporar y Closed 23CCR 2670 <br />REHS T,�EvE, INSPECTION DATE/TYPE: lZZ51 /—d16-ip.4Z <br />RECEIVED BY: <br />PHONE: <br />Revised Date 7/15/97 23 CCR UST Regs May 5, 1994 PAGE;—' of Z <br />PHS 231 (9/97) <br />