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SAN JOAQUIN COUNTY <br />&NVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, California 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (USTI PRnr.RAM INRP1=(MMI QI~onoT <br />Facility name: <br />►'fit J' �- YD CCS yIG <br />Design ed Operator:Inspection <br />Y►t o Date:" i/fe_, <br />Facility addre/s� <br />D I v �C"�Grlt "YJl f J� i�'I <br />UST # <br />'Product <br />Facility Contact: <br />Title: Phone: <br />to <br />MpgjtpriT <br />Piping system: <br />Overfill prevention: <br />❑Pressurized 11 Suction 11 Gravity <br />11 Mechanical 11Audible/visual <br />Inspection <br />ction type: <br />Violations: <br />❑ Routine ❑Monitoring Certification ❑ Installation ❑ Other: <br />❑ M1-RDetect ❑ M2-RPrev ❑ M-3 Both <br />odeSection <br />VIOLATIONS) HSC=California Health & Safety Code; CCR=California Code of Regulations VF#Tc R <br />V=Violation; RV=Re eat Violation V <br />1 HSC 25284 <br />Permit tooperate <br />2 CCR 2637 <br />Secondary containment test performec 7 -� -,. raIq <br />3 CCR 2711 b & c <br />Current Unified Program Consolidated Forms on file with EHD Faci ity and tank form <br />4 HSC 25292.2 <br />Certification of financial responsibility and CFO letter S— -790q <br />5 CCR 2632 b <br />Monitoring Program(Monitoring & Response Plan is current and approved by the local agency. <br />6 CCR 2712 i <br />Monitoring Ian is onsite. <br />7 CCR 2712 b <br />Maintenance & monitoring records M1) <br />8 CCR 2643 d <br />Daily monitoring of suction piping (pre -January, 1, 1984 <br />9 HSC 25292.1 <br />UST system isoperated to prevent unauthorized release <br />10 1 CCR 2632 (c)(2) <br />UST monitoring system is present (M1) <br />11 CCR 2630 d <br />UST system monitoring equipment is properly located to detect a leak M1) <br />12 HSC 25291 b <br />UST system monitoring equipment is operational (M1) <br />13 CCR 2636 (f)(1) <br />Continuous monitorings stem for underground piping & UDC is present (M1 <br />14 CCR 2631 a <br />Primary containment is product tight <br />15 HSC 25291 (a)(2) <br />Secondary containment for UST is tight <br />16 CCR 2636 (c)(1) <br />All releases in secondary piping flow to a collection sum <br />17 HSC 25291 <br />Line leak detectors are installed (M1) <br />18 CCR 2635 (b)(1) <br />Spill container (M2) <br />19 CCR 2635 (b)(2) <br />Overfill prevention system (M2 <br />20 CCR 2636 (a) <br />Conventional suction piping shall have continuous monitoring & 20 containment <br />21 HSC 25291 (e) <br />Water in 20 containment analyzed & properly disposed of <br />22 CCR 2650 <br />Recording/reporting of unauthorized releases (M1) <br />23 CCR 2715 <br />Designated Operator: a Statement from UST owner; (c -e) Monthly inspection; Employee training <br />24 CCR 2638 a <br />Annual monitoring certification =22 Q <br />25 CCR 2638 a <br />Annual line leak detector test M1 <br />26 HSC 25284.2 <br />Annuals ill containment testing <br />'27 CCR 2636 4 <br />Annual line tightness test (M1 <br />28 CCR 2661 <br />Repair for tank/piping has had tightness test (M2) <br />29 CCR 2643 a <br />Biennial tightness test of gravity piping(pre-January 1, 1984 <br />30 CCR 2643 d <br />Triennial line test for conventional suction piping (pre -January 1, 1984) (M1) <br />31 HSC 25292.5 <br />Double walls stem located within 1000' of public well-ELD <br />32 CCR 2661 <br />Permit to repair UST system <br />33 HSC 25286 a <br />Permit to alter monitoring system <br />34 HSC 25298 b <br />Permit to temporarily close UST system <br />35 HSC 25298 c <br />Permit to close UST system <br />36 HSC 25299 <br />Disabling leak detection devices <br />a 9 2 <br />37 HSC 25298 a <br />Illegal abandonment of UST system <br />38 Other: <br />EHDi__-I <br />PHONE: <br />UIC <br />r— —PECTOR: <br />Septic system: <br />❑Serves _>20 people/day <br />RE D BY <br />TITLE: <br />Laj <br />❑ Receives other than sanitary waste <br />All <br />/ <br />Other disposal methods: <br />I • <br />❑ Dry wells/French Drains <br />EHD 23-02-002 REV 8/08 <br />