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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 City S7 GfM�'n ZipQ�� <br /> UST: Dual Wall Single Wall RFILL: Audible Visual_Mechanical <br /> PIPING SYSTEM: bual wall Single wall >< Suction�_Pressure Gravity <br /> DOES THE LEAK DETECTION SYSTEM meet 23CCR 2636 (g) -requirements? YES NO <br /> VIO T ONS <br /> UST GENERAL REQUIREMENTS TANK # <br /> Permit to Operate [H&SC 252841 <br /> Forms A & B Current H&SC 25284 c <br /> Monitorin Maintenance Records 23CCR 2712 b <br /> Monitorin Records Available 23CCR 2712 i <br /> Monitoring Plan [23CCR 2632 (d) (1) <br /> Unauthorized Releases Reported [H&SC 252951 i <br /> Monitoring Equipment Annual Cert. 23CCR 2630 <br /> Over spili ContainEr <br /> Cathodic Protection 23CCR 2635 a 2 A <br /> New USTs Monitored Continuously [23CCR 26301 <br /> JE— <br /> MANUAL INVENTORY RECONCILIATION (MIR) <br /> U.c;T Tnt7,f-Writy_TP.-Zt- F21= 9,94311I <br /> Meters libr 2 R 2646M1 <br /> Monthly Variations Calculated [23CCR 2646 (d) ] <br /> 4x-variation Procedure O owe e <br /> SIATTSTTCAL INVENTORY RECONCILIATION (SIR) <br /> Inconclusive Procedure Followed (23CCR 2646.1 (d) ] <br /> UST Integrity Test Every Two Years 23CCR 2646.1 (q) ] <br /> Annual SIR Report [23CCR 2646'.1(j) ] <br /> Daily Stick Reacting c <br /> -AUTOMAITC TANK nAjjQTNn (ATC.) <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 es 4 <br /> lank Gauging Procedure Polloweci <br /> I4 <br /> Daily uction Pipiag Monitorincr r23CCR App. IIIh <br /> Piping Ti fitness 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 /> Ymnual UeNke c o <br /> i <br /> TANK REMOVAL <br /> Permit to Close or Cease Operation H&SC 25298 <br /> Removed, C ose or Temporar y C ose 23CCR 2670 <br /> REHS43h INSPECTION DATE/TYPE: <br /> RECEIVED BY: PHONE: <br /> Revised Date 7/15/97 23 CCR UST Regs May 5, 1994 PAGE_/ _of <br /> PHS 231(9197 <br />