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S A N J D AR I N Environmental Health Department <br /> TUU ;,�j i y <br /> Underground Storage Tank Program Inspection Report <br /> Facility Name: Facility Address: Date: <br /> Super Store Industries-Grocery Division 16888 McKinley Ave, Lathrop October 27, 2021 <br /> Other Violations <br /> 2010 See below Unlisted General violation ❑V ❑R ❑COS <br /> SUMMARY OF VIOLATIONS <br /> (CLASS I,CLASS II,or MINOR-Notice to Comply) <br /> Item# Remarks <br /> 109 CCR 2715(a)(1)(B),2715(a)(3) Failure to submit"Designated Underground Storage Tank Operator Identification <br /> Form"within 30 days. <br /> OBSERVATION:An outdated designated operator identification form was uploaded into CERS on 9/22/2021. <br /> REGULATION GUIDANCE: Effective 10/1/2020, the updated Designated UST Operator Identification Form shall be <br /> used when uploading into CERS. <br /> CORRECTIVE ACTION: Immediately log into the California Environmental Reporting System (CERS)at <br /> http://cers.calepa.ca.gov and upload the updated 10/1/2020 Designated UST Operator Identification form into <br /> CERS. <br /> This is a minor violation. <br /> 115 CCR 2638(c), 2638(d) Failure to submit"Monitoring System Certification Form"within 30 days of completion of the <br /> test. <br /> OBSERVATION:Annual monitoring system certification and leak detector testing was performed on 10/12/2020 and <br /> a test report was submitted on 11/25/2020, 1 months late. <br /> REGULATION GUIDANCE:A copy of the test report must be submitted within 30 days of the tests. <br /> CORRECTIVE ACTION: Take all necessary precautions to ensure testing and submittal of test reports are <br /> performed in a timely manner. <br /> This is a minor violation. <br /> 116 CCR 2637.1(d), 2637.1(e)Failure to submit the"Spill Container Testing Report Form"within 30 days. <br /> OBSERVATION:Annual spill container testing was performed on 10/12/2020 and a test report was submitted on <br /> 11/25/2020, 1 months late. <br /> REGULATION GUIDANCE:A copy of the test report must be submitted within 30 days of the tests. <br /> CORRECTIVE ACTION: Take all necessary precautions to ensure testing and submittal of test reports are <br /> performed in a timely manner. <br /> This is a minor violation. <br /> Overall Inspection Comments: <br /> Complete and submit a copy of the Return to Compliance Certification form to the EHD with a statement <br /> documenting the corrective actions that have been or will be taken for each violation, and any supporting <br /> paperwork, by 11/26/2021 . <br /> To minimize person to person contact EHD is choosing to write the name of person receiving the report instead <br /> FA0003833 PR0232523 SCO01 10/27/2021 <br /> EHD 23-01 Rev.9/16/2020 Page 4 of 5 Underground Storage Tank Program OIR <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/EHD <br />