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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 T (UST) PROGRAM INSPECTION REPORT <br /> Facility NameY: 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(g) requirements? YES NO <br /> VIO TIONS <br /> TANK # <br /> UST GENERAL REQUIREMENTS <br /> Permit to Operate [H&SC 25284] <br /> Forms A & B Current &S 52 8 4 j JD c <br /> MonitoringIMaintenance Records 23CCR 2712 b <br /> Monitoring Records Available r23CCR 2712 <br /> Monitorin Plan 23CCR 2632 (d2 (111 <br /> F.eapnnse Plan r21CCR 2632 (d) (5-01 <br /> Unauthorized Releases Report d [H&SC 25295] <br /> Monitoring Equipment Annual Cert. 23CCR 2630 <br /> ver sD!li Container <br /> Cathodic Protection 23CCR 2635 a 2 A <br /> New USTs Monitored Continuously [23CCR 2630] <br /> MANUAL INVENTORY RECONCILIATION (MIR) <br /> Meters Calihrited <br /> Monthly variations Calculated [23CCR 2646 (d) ] <br /> x- aria ion roc- ure -Followed e <br /> Inconclusive Procedure Followed [23CCR 2646.1 (d) ] <br /> UST Integrity Test Every Two Years L23CCR 2646.1 <br /> Annual SIR Report [23CCR 2646.1(j) ] <br /> Daily Stick Re-a-d-i—ng C <br /> Monthly ATG Results [23CCR 2643 (b) (1) ] <br /> Annual ummary epor <br /> MANUAL UST TANK GAUGING ( G) <br /> Tank Gauging Weekly [23CCR 2645 (b) ] <br /> 7=9I Tank "Integrity-Tt-su- <br /> an au Ing roc- ure FoIlowed <br /> Pij2iaq 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 /> TANK REMOVAL <br /> Permit to-Close or Cease Operation H&SC 25298 <br /> -move os or T porar y Closed23C 2 70 <br /> RENS INSPECTION DATE/TYPE <br /> RECEIVED BY: PHONE: Z <br /> Revised Date 7/15/97 23 CCR UST Regs May 5, 1994 PAGE Of <br /> PHS 260 (4/98) <br />