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PR0231906—420 W Kettleman Ln, Lodi Inspection Checklist January 18, 2023 Environmental Health Department SAN.JOAQUIN - -CC)U fVTY Underground Storage Tank Program Inspection Report Date: Facility Name: (� Facility Phone: �26tan rV \-V O Bw }I CERS ID: Facility Address: 4 vv do Inspection Contact: Title: Inspection Type: Program: Consent For: �� / Consent Given By: '� ®IIE ns ection Photos Er Samples S n `" Exp.Date: Z Ex Date: Dest Hated Operator: AY Service Technician Onsite: p' e>�e 1 ` 2� ServiiceTechnician Manufacturer's Training: V R 10!ti `-21+' (btu 13h-4- 15 1 2`Teg EHD=EnvIronmentai Health Cepanment CCR=Title 23 California ode of Regulations HSC Health and Safety Code CFR=Code of Federal tenon tionSR J Repeat violation COS=Corrected an sae during tnspec4on V=Violation File Review ❑V aR aC05 101 HSC 25284;CCR Failure to obtain a permit to operate from the EHD including but not limited to unpaid permit fees 2711(d) fl V ❑R p COS 102 CCR 2711 Failure to submit a complete and accurate application for a permit to operate a UST a V o R a COS 103 CCR 2635(l1,2636(c)(2) Failure to submit the UST Certification of Installatiorl✓Modification V rs R U COS 104 CCR 2632(d)(1), Failure to submit a complete and accurate UST Monitoring Plan 2634(d) o V o R o COS 105 CCR 2632(d)(2), Failure to submit a complete and accurate UST Response Plan 2634(e) o V ❑R a COS 106 CCR 2632(d),2641(h) Failure to submit and maintain a current facility plot plan!site map V aR aCOS 107 HSC 25292.2;CCR Failure to submit and maintain complete and current financial responsibility documents ❑ 2711(a)(11) c V a R o COS 108 CCR 2620(b);HSC Failure to implement or maintain a written agreement between fire UST owner and operator 25284(a)(3) a V a R c COS 109 CCR 2715(a)(1)(B), Failure to submit"Designated Underground Storage Tank Operator Identification Form"within 30 days 2715(a)(3) G V a R c COS 110 CCR 2715(a)(1)(A), Failure to submit the"Underground Storage Tank Statement of Understanding and Compliance Form" 2715(a)(2) o V a R a COS 111 CCR 2637,2638(e), Failed to notify the EHD 48 hours prior to conducting testing 2643(g) ❑V ❑R a COS 112 CCR 2638,26410), Failure to have properly qualified service technician test leak detection equipment every 12 months 27150 =R c COS 113 CCR 2637(a-d),2712(b) Failure to conduct secondary containment testing (T)(F) =V =R ❑COS 114 CCR 2631 2643(c) Failure to perform line integrity test every 12 months or within 30 days of repair of primary pipe (3) r COS 115 CCR 2638(c),2638(d) Failure to submit"Monitoring System Certification Form"within 30 days of completion of the test 116 CCR 2637.1(d), Failure to submit the"Spill Container Testing Report Form"within 30 days Vd WR =COS 2637.1(e) 117 CCR 2637(e),2637(f) Failed to submit"Secondary Containment Testing Report Form"within 30 days after the test VV v< =Cos 118 CCR 2637.2(d&e), Failure to submit the"Overfill Prevention Equipment Inspection Report Form"within 30 days c R o COS 2665(a&b) 119 CCR 2663, 2712(b)(6) Failure to comply with tank lining certification,testing,inspection,and record requirements a V a R c COS 120 CCR 2631,2640.1, Failure to submit and/or maintain documentation regarding compatibility for UST system components a V a R a CO: 2665,2711 Page 1 of o UndWWWd TO*Pmyram 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.5jg0V.0rWEHd