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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 o " —Program ID# <br /> Facility Address, �� Citl <br /> v y Zip <br /> UST: Dual Wall2!�­Single Wall OVERFILL: Audible ViRrighl Mechanical <br /> PIPING SYSTEM: Dual wall Single wall Suction Pressure Gravity <br /> DOES THE LEAK DETECTION SYSTEM meet 23CCR 2636 (8) requirements? YESNO <br /> VIOLATIONS <br /> TANK # <br /> UST GENERAL REQUIREMENTS <br /> Permit to Operate [H&SC 252841 <br /> Forms A & B Current H&SC 25284 c <br /> monitoring/maintenance Records r23CCR 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 Annual Cert. 23CCR 2630 <br /> ver s i on ainer [23CCR 2635 (b)l <br /> Cathodic Protection 23CCR 2635 a 2 A <br /> New USTs Monitored Continuously [23CCR 2630] <br /> MANUAL INVENTORY RECONCILIATION (MIR) <br /> UST Tntparitv Test 121CCR 2943-11 <br /> Meters <br /> Gauging Stick in 1�8 Inches r23CCR 2646 (c) (1) (F) l <br /> Monthly Variations Calculated [23CCR 2646 (d) ] <br /> EX-Variation Procedure Followed L23CCR—=. (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 /> AUT MAT-rC TANK GAUGING (ATG) <br /> Monthly ATG Results [23CCR 2643 (b) (1) ] <br /> Annual ATG Summary Report <br /> MANUAL UST TANK GAUGING (MTG) <br /> Tank Gauging Weekly [23CCR 2645 (b) ] <br /> Annual Tankn egri y Test <br /> iank Gauging Procedure kolloweU <br /> PING MQNTTORTNr. <br /> Daily Suction Piping monitoring r2 R App.III <br /> Piping Tightness Test 23CCR 2643 b c d <br /> Gravity Piping Tested Every 2 Years [23CCR 2643 (e) ] <br /> Mont ly Line Test L23CCR 2643 c 2 <br /> Annual e <br /> TANK REMOVAL 'W <br /> Permit to'Close o Cease Operation H&SC 25298 <br /> Remove , ose o Temporar Closed 23CCR 2670 <br /> REHS I/NSPECTION 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 />