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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 TANK PROGRAM INSPECTION REPORT <br />Facility Name 1– ® Program ID# -- <br />Facility Address a� 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 />mnuu �+ <br />UST GENERAL REQUIREMENTS _.�.., <br />Permit to Operate [H&SC 252841 <br />Forms A & B current H&SC 25284 c <br />Monitoring/Maintenance Records r23CCR 2712 b <br />monitoring Records Available 23CCR 2712 <br />Monitoring Plan [23CCR 2632(d)(1)] <br />Response Plan r23CCR 2632(d)(2)] <br />Unauthorized Releases Reported [H&SC 25295] <br />Monitoring Equipment Annual Cert. 23CCR 2630 <br />Over spiii Container <br />Cathodic Protection 23CCR 2635 a 2 A <br />New USTs Monitored Continuously [23CCR 2630] <br />MANUAL INVENTORY RECONCILIATION (MIR) <br />meters ali ra ed 23CCR 2646(i)] <br />Gauging Stick in 128 inches r23CCE 2646(c)(I)(E)] <br />Monthly Variations Calculated [23CCR 2646(d)] <br />—Ex -Variation Procedure i-oiiowed L23CCR 2646(e)j <br />STATISTICALL ATI IR <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 Reading (c)(1)J <br />Monthly ATG Results [23CCR 2643(b)(1)] <br />nua summaryepor <br />MANUAL UST TANK GAUGING (MTG) <br />Tank Gauging Weekly [23CCR 2645(b)] <br />Annual lankn egri y rest <br />7ank Gaugirig Proceaure kolloWed <br />Daily Suction Piping Monitoring r2 CR ADD.II1 <br />Piping Tightness Test 23CCR 2643 b c d <br />Gravity Pipina Tested every 2 years [23CCR 2643(e)] <br />Monthly Line Test L23CCR 2643 c (2 <br />Annuai LeakDetector e <br />TANK REMOVAL <br />Permit to close or cease operation H&SC 25298 <br />Removed, Closed or Temporar y closed 23CCR 2670 <br />4R!EHS.IFINSPECTION DATE/TYPE :f° <br />l <br />! t<® <br />PHONE. C ! J <br />®D <br />Revised Date 7/15/97 23 CCR UST Regs May 5, 1994 PAGEof <br />