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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 />�tpG <br />Facility Nameff'f7 '' tt ✓'/e�jf .�1`/Program ID# a3�i/ -7 9 <br />Facility Address i70/ O( /n,/„$ rh., City ��bG�'7Uh Zip `/5a0 <br />UST: Dual Wall l Single Wall OVERFIIJ6 AAudible Visual Mechanical <br />PIPING SYSTEM: Dual wall Single wall_�Suction::ZPressure Gravity <br />DOES THE LEAK DETECTION SYSTEM meet 23CCR 2636(8) requirements? YES NO-�Z— <br />aeuvn � <br />UST GENERAL REQUIREMENTS <br />Permit to Operate [H&SC 25284] <br />Forms A& B Current H&SC 252 4 c <br />Monitoring/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 Re orted [H&SC 252951 <br />Monitoring Equipment Annua Cert. 23CCR 2630 <br />over spill on ainer <br />Cathodic Protection 123CCR 2635 a 2 A <br />New USTs Monitored Continuously [23CCR 2630] <br />MANUAL INVENTORY RECONCILIATION (MIR) <br />Meters Calibrated r23CCR 2646(i)l <br />Monthly Variations Calculated [23CCR 2646(d)] r <br />Ex -variation Procedure Followee)j <br />-STATISTICAL INVENTORY RECONCILIATION (SIR) �a69- <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 Reaaing c <br />-A=OMATIC TANK GAUGING (ATO) <br />Monthly ATG Results [23CCR 2643(b)(1)] <br />Annual Summary Report <br />MANUAL UST TANK GAUGING (MTG) <br />Tank Gauging Weekly [23CCR 2645(b)] <br />Annual an n egri y lest <br />iank Gaugingroce ure Pollowed <br />Daily Suction Piping M <br />Piping Tightness Test 123CCR 2643 b c d <br />Grayit Pi in Tested Ever 2 Yars [23CCR 2643(e)] <br />Mont y Line Test 23CCR 2643 ce2 <br />TANK REMOVAL <br />Permit to Close or Cease Operation H&SC 25298 <br />-IFe-movea, uloseaor Temporar y Closed R 2 70 <br />REHSt��/ (�,CyQi INSPECTION DATE/TYPE: !o '�� - Y L �✓li S�2Qg4 �.(�j S' <br />RECEID BY: PHONE: <br />Revised Date 7/15/97 23 CCR UST Regs May 5, 1994 PAGE_of <br />PHS 260 (4/98) <br />