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ur I Environmental Health Department <br />41 t: SAN-6-JOAQU <br />vii fir: C (--) LJ Y Time In: <br />r <br />Time Out: <br />r'�JFOSX:, Careotness grows here. <br />Underground Storage Tank Program Service Request Inspection Report <br />Name of Facility: C -STORE W/76 FUEL ISLAND <br />Date: 05/26/2020 <br />Address: 141 E HARNEY LN , LODI 95240 <br />Requestor: MEL HIGGINBOTHAM, PM DESIGN GROUP INC <br />Telephone: (530) 303-2814 <br />Program Element: 2303 - UST/PIPING INSTALLATION <br />Request #: SR0079417 <br />Inspection Type: 131 - UST INSTALLATION INSPECTION <br />Onsite Service Technician: Steven Jones <br />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 leak monitoring communication for all installed VPH components. <br />-Verified installation of test ports. No additional shut off valves were observed. <br />-Verified VPH component installation. <br />-Inspected dispenser footprints and UDCs. Piping is contained within the UDCs, but filters are not. Deflector plates are <br />needed. <br />-Witnessed audible/visual alarm for overfill prevention and verified 90% measurements. <br />-Witnessed one hour hydrostatic testing of all three spill containers. All passed. Verified 5 gallon capacity for all spill <br />containers. Drainage was not tested. <br />-Witnessed functionality testing of monitoring system certification. All passed. <br />"*This facility is NOT approved for fuel delivery." <br />Items needed in order to receive approval for fuel delivery: <br />-A valid CDTFA number must be obtained and provided to EHD. <br />-Proper spill container drainage method must be verified. <br />-Installation of deflector plates must be verified. <br />"Additional inspections are still needed. See approval letter dated December 5, 2019 for required inspections. <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: <br />EH Specialist: STACY RIVERA <br />Name and Title: <br />Phone: (209) 468-3440 <br />SR0079417 SC131 05/26/2020 <br />EHD 23-01 Rev. 06/30/15 Page 1 of 1 Underground Storage Tank Program Service Request Inspection Report <br />