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Time In: <br /> Time Out: <br /> opQ.�tN. San Joaquin County <br /> .X Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • �... P Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sigov.org/ehd <br /> �<<FORtN <br /> Underground Storage Tank Program Service Request Inspection Report <br /> Name of Facility: C-STORE W/76 FUEL ISLAND Date: 06/04/2020 <br /> Address: 141 E HARNEY LN , LODI 95240 <br /> Requestor: MEL HIGGINBOTHAM, PM DESIGN GROUP INC Telephone: (530)303-2814 <br /> Program Element: 2303-UST/PIPING INSTALLATION Request#: SR0079417 <br /> Inspection Type: 131 -UST INSTALLATION INSPECTION <br /> Onsite Service Technician: Steven Jones ICC Service Tech/Installer Exp. Date: 08/05/2021 <br /> Manufacturer training: VR, 07/21/21; OPW, 01/16/21 <br /> OVERALL INSPECTION NOTES AND COMMENTS <br /> NOTES <br /> On site for the following: <br /> -Verified proper spill container drainage method on all spill containers. <br /> -Verified the installation of deflector plates on all UDCs <br /> -The site has a valid California Department of Tax and Fee Administration (CDTFA)number.A valid CDTFA number <br /> (238560640)was received by EHD on 6/2/2020. <br /> 'This facility is approved to receive fuel, not to operate. <br /> NOTE-Additional inspections are still needed. See approval letter dated 12/5/2019,for required inspections. <br /> To minimize person to person contact EHD is choosing to write the name of person receiving the report instead of having them <br /> sign. <br /> The person in charge is responsible for ensuring that the above mentioned facility is in compliance with all applicable sections of the California Health and <br /> Safety Code.If a reinspection is required,fees will be assessed at the current hourly rate. <br /> Received by: Name and Title: Steven Jones, Service Tech <br /> EH Specialist: SHEWIT WOLDEAREGAY Phone: (209)468-0216 <br /> SR0079417 SC131 06/04/2020 <br /> EHD 23-01 Rev.06/30/15 Page 1 of 1 Underground Storage Tank Program Service Request Inspection Report <br />