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PUBLIPHEALTH SERVICES SAN JOA QUOICOUNTY <br />ENVIRONMENTAL HEALTH DIVISION <br />304 E. Weber Ave., Third Floor, Stockton, CA 95202 <br />(209) 468-3420 <br />UNDERnUND S O GE <br />Facility Name <br />Program ID# <br />Facility Addressi-6' Mh 6�1/&kity zip <br />UST: Dual Wall Z.Single W OVERFILL: Audible Visual Mechanical=:/: <br />PIPING SYSTEM: Dual wall- -*' S-1—ngle wall Suction Pressure Gravity_ <br />DOES THE LEAK DETECTION gYSTEM meet 23CCR 2636(8) requirements. YES NO <br />VIOLATIONS <br />UST GENERAL REQUIREMENTS <br />Permit to Operate [H&SC 25284] <br />Forms K -6i B'gu <br />. �rrent�R&0 25284 jb2 (c) j <br />monitoringlmaintenance Records [23CCR 2712(b)) <br />Einangial RpRnnnsihilitv NMC 2q292-2(a)l <br />Monitoring Records Available [23CCR 27121 <br />Monitoring Plan [23CCR 2632(d)(1)] <br />RAnnnnsa Plan r23CCR 2612(d)(2)l <br />Unauthorized Releases Re2orted [H&SC 25295] <br />Monitoring Equipment Annual Cert. [23CCR 2630(dTr— <br />Uver sl ConEain—e—r-72= 2635(B)j <br />2er-mitted JIST Rpnairgq r2lrC-'R 26611 <br />Re :Mjf-j-aA Uncrraapq rg.-Arrp ;�gs;nl <br />Cathodic Protection [23CCR 2635(a)(2A)j <br />New USTs Monitored Continuously [23CCR 2630] <br />MANUAL INVENTORY RECONCILIATION (MIR) <br />-TTST Tntpca: ty TV.8 43.3 <br />Anmi=l MTP P.=Y,nyj- rqirrp 99A6Z1rT)1 <br />Meters <br />[23Cr-R 2646 (c) (3)1 <br />aucrincr —Stink in I/R Tncheg r23C-r-R 2fjAfj (C) (3) (ELL— <br />Monthly Variations Calculated [23CCR 2646(d)] <br />--Ex---V—a-r-iar-ion Prote ure Followed L23CCR 2646(e)j <br />(SIR) <br />Inconclusive Procedure Followed [23CCR 2646.1(4)] <br />UST Integrity Test Every Two Years [23CCR 2646.1L <br />Annual SIR Report [23CCR 2646.1(j)] q)j_ <br />Daily is Reading [23CCR 2646 (c)(1)] <br />A=Q=IC TAM O&M (ATal <br />Monthly ATG Results [23CCR 2643(b)(1)] <br />Annual X7'G Summary lZeporf'"[23CCR 2712(B3 (2)j <br />MANUAL UST TANK GAUGING (MTG) Lh <br />Tank Gauging weekly [23CCR 2645(b)] AV k Ov <br />mmual an irlteqflty 79st L--Z-5UUX Zb4b (JD) j III V PVT <br />an au in rocsZ[urg Fo112wea <br />PTPTNr- MONTTORTMa A Q/ <br />12slily Suction Piping Monitoring r23CCR ADD. III <br />Pi in Tightness Test [23CCR 2643(b), " (c),(d)l U <br />Gravity Piping Tested Every 2 Years [23CCR-2643(e)] <br />Monthly Line Test 23CCR 2643(c)(2)] A <br />=IaaI BeaK Defecrof TEEF ZbJUta)i A <br />TANK REMOVAL <br />Permit to close or Cease Operation [H&SC 252981 <br />rzemoveed . or Temporar y ?!Iosed [23ZT1Z- 2670—j-- <br />REHS :2j INSPECTION DATE/TYPE: o�=7 7— <br />PRrRTvpn ny. Kv, DWOMP <br />-r. <br />Revised Date 7/5/97 23 CCR UST Regs May 5, 1994 PAGE -1,-of <br />PHS 239 (9/97) <br />