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r ` A N , Q Q N Environmental Health Department Y Ciril , tnc` = i r) rr ls < <tore , Underground Storage Tank Program Inspection Report Facility Name: Facility Phone: Date: CHEVRON STATION #94275' (209) 478-5555 June 12 , 2019 Facility Address: CERS ID: 2905 W BENJAMIN HOLT DR , STOCKTON , CA 95207 10181335 Inspection Contact: Title: Phone: Kenisha Jenkens Store Manager (209) 478-5555 Inspection Type : Program: ROUTINE INSPECTION - Operating Permit 12351 - UST FACILITY - 2481 COMPLIANT Consent For: Consent Given By: x❑ Inspection ❑x Photos 0 Samples Ruvian Laurel , Assistant Manager Service Technician Onsite: Exp . Date: Designated Operator: Exp. Date: Jesus Saldivar 06/16/2019 Rayana Black 11 /09/2020 Service Technician Manufacturers Training : VMI , 11 /20/ 19 ; VR , 04/28/21 , SB , 06/09/22 CCR = Title 23 California Code of Regulations HSC = Health and Safety Code CFR = Code of Federal Regulations V = Violation R = Repeat violation COS = Corrected on site during inspection File Review 101 HSC 25284 Failed to obtain a permit to operate from the EHD including but not limited to unpaid permit fees ❑ V ❑ R ❑ COS 102 HSC 25284(a) (3) (A)/(B) No written agreement between tank owner and tank operator to monitor the tank system ❑ V ❑ R ❑ COS 103 HSC 25292.2, 25299 .30 Failure to submit and maintain complete and current financial responsibility documents ■ V ❑ R ❑ COS 104 CCR 2711 UST operating permit application for facility and tank information not submitted or current ❑ V ❑ R ❑ COS 105 CCR 2632(d) (1 ) , Failed to have an approved UST monitoring plan ❑ V ❑ R ❑ COS 2634 (d) 106 CCR 2632(d) (2) , Failed to have an approved UST response plan ❑ V ❑ R ❑ COS 2634 (e) 107 CCR 2632(d) (1 ) (C) Plot plan/site map not submitted or failed to completely show where monitoring is performed ❑ V ❑ R ❑ COS 108 CCR 2637, 2638(e) , Failed to notify the EHD 48 hours prior to conducting testing ❑ V ❑ R ❑ COS 2643 (g) 109 CCR 2637(a-d) , 2712 Failed to test secondary containment, or failed to maintain test records for 36 months ❑ V ❑ R ❑ COS 110 CCR 2637(e) , 2637 (f) Failed to submit "Secondary Containment Testing Report Form" within 30 days after the test ❑ V ❑ R ❑ COS 111 CCR 2638 (a) & (b), Failed to test monitoring and leak detection equipment annually ❑ V ❑ R ❑ COS 26410) 112 HSC 25293 Failure to maintain UST records to enable the UPA to determine whether the UST is in compliance ❑ V ❑ R ❑ COS 113 CCR 2638(c) , 2638(d) Failure to submit "Monitoring System Certification Form" within 30 days of completion of the test ❑ V ❑ R ❑ COS 114 CCR 2636(f) (3) 1 2643(c) No 0. 1 gph annual line integrity test for pressurized piping , or within 30 days after repair ❑ V ❑ R ❑ COS (3) 115 CCR 2715(a) (1 ) (B) , "Designated Underground Storage Tank Operator Identification Form" not submitted within 30 days ❑ V ❑ R ❑ COS 2715(a) (3) 116 CCR 2715 Designated operator, service tech or installer did not possess current ICC certification ❑ V ❑ R ❑ COS 117 CCR 2663 , 2712 (b) (6) Failure to comply with tank lining , recordkeeping , and inspection requirements ❑ V ❑ R ❑ COS 118 CCR 2715(a)(1 ) (A) , Failure to submit the " Underground Storage Tank Statement of Understanding and Compliance Form" ❑ V ❑ R ❑ COS 2715(a) (2) 119 HSC 25299(a) (8) , Documents were falsified or misrepresented ❑ V ❑ R ❑ COS 25299(b) (7) 120 CCR 2635(d) Failed to submit UST Certification of Installation/Modification ❑ V ❑ R ❑ COS 121 CCR 2712(f) Failed to submit a written response within 30 days of receiving an inspection report ❑ V ❑ R ❑ COS 122 CCR 26313 2640. 11 Failure to submit and/or maintain documentation regarding compatibility for UST system components ❑ V ❑ R ❑ COS 2665 , 2711 FA0003712 PR0231952 SCO01 06/12/2019 EHD 23-01 Rev. 09/28/2018 Pagel of S Underground Storage Tank Program OIR 1868 E . Hazelton Avenue I Stockton , California 952051 T 209 468-3420 1 F 209 464-0138 I www. sjcehd . com