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PUBLIPHEALTH SAN QU SERVICES OA I C <br />C J OUNTY <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,j-L� �/!/i f Program ID# <br />Facility Address %3�/ � City 4pol 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 F23CCR 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 />over spili Container IT= 2635(b)j <br />Cathodic Protection 23CCR 2635 a 2 A <br />New USTs Monitored Continuously [23CCR 2630] <br />MANUAL INVENTORY RECONCILIATION (MIR) <br />UST Tntparitv Test F21CCR 2943.11 <br />Meters li rated r23CCR i <br />Monthly Variations Calculated [23CCR 2646(d)] <br />x- aria ion Procedure Foiiowea L23CUR 2b4b(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 Reaaing c <br />AUTOMATIC TANK GAUGING (ATG) <br />Monthly ATG Results [23CCR 2643(b)(1)] <br />Annuai Alu 6ummary Report <br />MANUAL UST TANK GAUGING (MTG) <br />Tank Gauging Weekly [23CCR 2645(b)] <br />Annual lankn egri y lest <br />Tank GaugIng Proceaure Followea <br />PIPING MONITORING <br />Daily u tion Piping monitoring r2 CR ADD.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 />Annual e <br />TANK REMOVAL <br />Permit to Close or Cease Operation H&SC 25298 <br />Removed, Closed or Temporar y C ose 23CCR 2670 <br />REHS '? INSPECTION DATE/TYPE:FiOg <br />RECEIVED BY: PHONE: / <br />Revised Date 7/15/97 23 CCR UST Regs May 5, 1994 PAGE_/_of <br />PHS 231 (9/97) <br />