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PUBLIPHEALTHSERVICES SAN JOAQU4NOCOUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 E. Weber Ave. , Third Floor, Stockton, CA 95202 <br /> (209) 468-3420 <br /> UNDERGROUND STORAGE T (UST) PROGRAM INSPECTION REPORT <br /> Facility Name 4 Program ID# <br /> Facility Addressp� 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 O—STEM S -STEMmeet 23CCR 2636 (g) requirements. YES NO <br /> VIOLATIONS <br /> TANK # <br /> UST GENERAL REQUIREMENTS <br /> Permit to Operate [H&SC 252841 <br /> Forms A & B Current H&S 25284 jc <br /> Monitoriaglmaintenance Records 23CCR 2712 b <br /> Monitoring Records Available 23CCR 2712 <br /> Monitorin Plan [23CCR 2632 (d) (1) ) <br /> Unauthorized Releases Reported [H&SC 25295] <br /> Monitoring Equipment Annua Cert. 23CCR 2630 <br /> ver s a on ainer <br /> Cathodic Protection 23CCR 2635 a 2 A <br /> New USTs Monitored Continuously [23CCR 26301 <br /> MANUAL INVENTORY RECONCILIATION (MIR) <br /> Mgjgrg Calibrated R2616 (ill <br /> Monthly Variations Calculated [23CCR 2646 (d) ] <br /> x- aria ion Procedure Followect L23CCR 2646 (e) j <br /> Inconclusive Procedure Followed [23CCR 2646.1(d) ] <br /> UST Integrity Test Every Two Years 23CCR 2646.1 qj <br /> Annual SIR Report [23CCR 2646.1(j) ] <br /> D—al=y"Stick Reacting c <br /> Monthly ATG Results [23CCR 2643 (b) (1)] <br /> A—=uaI ATG Summary epor <br /> MANUAL UST TANK GAUGING ( G) <br /> Tank Gauging Weekly [23CCR 2645 (b) ] <br /> Taffu= Tank IntegrIty es <br /> --Tanic GaugingProcedure FTLIbwed <br /> Daily u i n Pining Monitoring 2 R Ano.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 /> Ariflue <br /> TANX REMOVAL <br /> Permit to Close or Cease Operation H&SC 25298 <br /> Removea, Close or-Tm war y Closed 23CCR 2670 <br /> REHStv, 20aNSPECTION DATE/TYPE: .-. <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 />