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San Joaquin County Environmental Health Department UNDERGROUND ST"&AGE TANK SYSTEM 1868 East Hazelton Avenue,Stockton,California 95205-6232 Telephone:(209)466-3420!ax:(209)468-3433 web:www s mw om/eha DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT RETURN TO COMPLIANCE CERTIFICATION FacilityName: CO (1 V/Y Facility Address: y.055 S. S M �V City: S-foG `I, Any MINOR violations noted in the'Notes to Comply'in the attached Inspection Report must be corrected within 30 days of Name ofDesipMed USTOperemr Conducting Inspection: Guadalupe Sanchez receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address at the top of this form within 30 days of receipt of the Inspection Report. HSC 26404.1.2(c)(1) Intemetionel Code Contrail CertlficmionNo.: 5250451-UC Expiration Date: 219/2015 All corrections to other violations noted in the attached Inspection Report(IR)or Continuation Form,or disputes to any S'�a Phone: (209)6049363 ea. violations,are to be submitted using this certification and returned to EHD within 30 daps unless otherwise specified in the N/A=Not A iuble —1utrection Report. HSC 25185(c)(3)--- Item MONITORING PANEL/ALARM HISTORY - Y.1No I-N/A L Is the monitoring tem Powered on and in proper operating mode? Note:All EHD staff time associated with failing to comply by the above noted dates will be 2. Is the monitoring tem not currently showing my leak alarms? Li billed at the current hourly rate. 3. Is the Alarm History Reportnog for the previous month available,and has it been reviewed by the Designated UST tor? Affach a copy o the alone histcLv repo og to this im ecdon arm. For this certification to be complete, theoperatorofthe site must include: 4. Has each alannfar the previousmonth been responded m natel ? A statement documenting what corrective actions were taken or will be taken for each violation UST SYSTEM INSPECTION Copies of sample resulWmanifestsRraming records/other appropriate paperwork,and/or photos verifying 5. Aretank-top cone rreentsumps free ofewter,debris,andhamrdous substance? Non:/Jdemuw=,ro/cemewd"re,,-,ny ctlons o;1.6 aSlmmzryane 4wMNee raunuceatomtln hudraamttupnmMamneymrMems calmvNa woaN mara rano h tripx eXnrvNkUeaabc9wmNl�hedarXmervlw1¢d rko dNnni tlan Mr roeYreagadNeo s acCOirron Date: November25,2014 Inspected By: JEFFREY WONG sum l b,and Location, Some Location: Sump Location: somp Location: Facility Address: 4855 S HWY 99 EAST FRONTAGE RD,ST O EPA ID: 6. Amcill buckets(commitment ametmes fisc of water,debds,andbemrdme.aitstaice? Yes No N/A Yes No N/A I certify under penalty of law that Tmtkl ID- -+ Tank4IDi Li LJ LJ - 1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. c i Tank 2ID- Tank 6ID- e"v� Took 3ID- ❑ Tank 6ID- 2. 1 have personalty examined the following documentation submitted as proof of compliance FOR EACH VIOLATION 7. Are under-dispenser containment mem free of water,debris,and hazardous substance? and I believe the information to be true,accurate,and complete: YeaI No I N/A I Yee I No I N/A Dispenser-1/2 1 1 1 1 1 1 1 Dis ser-9/10 Photos ✓PaperworkStatement Di -3/4 Di m-11/12 ❑ D LVeresser-5/6 Diu m-13/14 3. l am authorized to submit this certification on behalf of the Respondent. I Dispenser-7/9 Dis r-15/16 •ITa+ 8. Leak detection is property located within under-dispenser containment 4. 1 am aware that there are significant penalties for submitting false information,Including the possibility of a fine Yes I No MIA Yes I No I N/A and/orimprisonme tforkhown violations. (HSC25191) D' ser-1/2 D' sm-9/10 1 Li I Li 1I per /� / Dispenser-3/4 Dis riser-11/12 Name: p�E>r til Title: Dispenser-5/6 1 1 Lj I Ll I Dispenser-13/14 �{ D' er-7/8 Dis er,cr-15/16 • r4,18 ❑ ❑ Signature: n L� / Date: �� v. PAPERWORK INSPECTION Yes Na N/A Date Done 9. 1 monito'but Svsupon Certification was completed within the man 12 months? Lj ❑ 11-19-f.3 10. Line Leak Detectors were tested/cerified within the past 12 months? Ll ❑ 1 /1-15-11 11. Spill bucket containment structure)testing completed within the rest 12 months? 6 -13 12. Line fightness testing completed within therequired rime more? ❑ 13. Secondary containment teas completed within the required time frame? •1 14. Enhanced Leak Detection completed within the required time from? 15. Other required teain maintenance was—completed within required time Game? List terdmabseeanre items below. Describe Test/Maintenance: 1-lS-l9 Describe Tesr/Mamtenance: -- ---- -- - ® -- --_ _- ---- FACILDY EMPLOYEE TRAINING as No N/A -. ■ l r �i N ` i- > 16. Have all facility employeesreceived the required on-the-job trainingwithin the as ear? ❑ 'r`e- 17. Have all facili employee a hired within the 30 da received the 'ped on-the=ob trainin 7 ■//��, : E answers in the"Comments"section on the following page.Those issues require corrective action from JAN0 6' R �/ m/" ww.unlm aura 9nbms ENViRGNMENI l'AL HEALTH JAN G G 2014 DEPARTMENT ENVIRONMENTAL HEALTH DEPARTMENT