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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 <br />Program ID# <br />Facility Address City 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 />UST GENERAL REQUIREMENTS <br />Permit to Operate [H&SC 252841 <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 />Response Plan [23CCR 2632 (d) (2) 1 <br />Unauthorized Releases Reported [H&SC 25295] <br />Monitoring Equipment Annual Cert. 23CCR 2630 <br />ver spill on ainer <br />Cathodic Protection 23CCR 2635 a 2 A <br />New USTs Monitored Continuously [23CCR 2630] <br />MANUAL INVENTORY RECONCILIATION (MIR) <br />Meters br R 2646(i)] <br />Monthly Variations Calculated [23CCR 2646(d)] <br />Ex -variation Procecture Foiiowed [23CCR 2646(e)] <br />STA.'ISTICAL 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 />AUTOMATIC TANK GAUGING (ATC) <br />Monthly ATG Results [23CCR 2643(b)(1)] <br />Annuai ATG Summary Report <br />MANUAL UST TANK GAUGING (MTG) <br />Tank Gauging Weekly [23CCR 2645(b)] <br />An <br />nua an n egri y Iest <br />Tank auging ProceCure ioiiowect <br />PIPING, MONTTORTNQ <br />Daily uc n Pilping monitoring f2 CR Alpip.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 />Annuai Leak LeteCtor iest <br />TANK REMOVAL <br />Permit to Close or Cease Operation H&SC 25298 <br />Removed, Closed or Temporar y Closed 23CCR 2670 <br />17:0&& <br />RECEIVED BY: <br />INSPECTION DATE/TYPE: <br />PHONE: <br />Revised Date 7/15/97 23 CCR UST Regs May 5, 1994 PAGE of <br />PHS 260 (4/98) <br />