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SAN JOAOUIN Environmental Health Department COUNTY Underground Storage Tank Program Inspection Report Facility Name: Facility Phone: Date : COUNTRY CLUB MOBIL CIRCLE K (209 ) 932- 1307 January 18 , 2023 Facility Address: CERS ID: 2575 COUNTRY CLUB BLVD , STOCKTON , CA 95204 10118074 Inspection Contact: Title: Phone: Inspection Type: Program : ROUTINE INSPECTION - Operating Permit 12351 - UST FACILITY - 2481 COMPLIANT Consent For: Consent Given By : Inspection ` hotos XSamples D v iYly ne ktl ?1 A CkMOIS Service Technician Onsitec Exp. Date: Designated Operator: Exp, Date: KmTl, Y \\ �, V2A DCM6 v r 2- i Service Technician Manufacturer's Training ' 3b � z� 2'� 'F'F 1 \ 2�cZI CCR = Titie23 MiltorniarGoaeot Regulations = Realin and Safety o e ClmK = ode of I- ecleral Regulations EHD = Environmental HealthDepartment V = Violation R = Repeat violation COS = Corrected on site during inspection File Review 101 HSC 25284; CCR Failure to obtain a permit to operate from the EHD including but not limited to unpaid permit fees V ❑ R ❑ COS 2711 (d ) 102 CCR 2711 Failure to submit a complete and accurate application for a permit to operate a UST ❑ V ❑ R ❑ COS 103 CCR 2635(f) , 2636 (c)(2) Failure to submit the UST Certification of Installation/Modification ❑ V ❑ R ❑ COS 104 CCR 2632(d ) ( 1 ) , Failure to submit a complete and accurate UST Monitoring Plan ❑ V ❑ R ❑ COS 2634(d) 105 CCR 2632 (d ) (2) , Failure to submit a complete and accurate UST Response Plan ❑ V ❑ R ❑ COS 2634(e) 106 CCR 2632(d) , 2641 ( h ) Failure to submit and maintain a current facility plot plan / site map ❑ V ❑ R ❑ COS 107 HSC 25292 . 2 ; CCR Failure to submit and maintain complete and current financial responsibility documentsV ❑ R ❑ COS 2711 (a) ( 11 ) 108 CCR 2620(b) ; HSC Failure to implement or maintain a written agreement between the UST owner and operator ❑ V ❑ R ❑ COS 25284(a) (3) 109 CCR 2715(a) ( 1 )(B) , Failure to submit "Designated Underground Storage Tank Operator Identification Form" within 30 days V ❑ R ❑ COS 2715(a) (3) 110 CCR 2715(a) ( 1 ) (A) , Failure to submit the " Underground Storage Tank Statement of Understanding and Compliance Form" ❑ V ❑ R ❑ COS 2715(a) (2) 111 CCR 2637 , 2638(e) , Failed to notify the EHD 48 hours prior to conducting testing ❑ V ❑ R ❑ COS 2643(g) 112 CCR 2638 , 26410 ) , Failure to have properly qualified service technician test leak detection equipment every 12 months ❑ V ❑ R ❑ COS 2715(f) 113 CCR 2637(a-d) , 2712(b) Failure to conduct secondary containment testing ❑ V ❑ R ❑ COS ( 1 ) (F) 114 CCR 2636 (f)(3) , 2643(c) Failure to perform line integrity test every 12 months or within 30 days of repair of primary pipe ❑ V ❑ R ❑ COS (3) 115 CCR 2638 (c) , 2638(d ) Failure to submit "Monitoring System Certification Form" within 30 days of completion of the test V ❑ R ❑ COS 116 CCR 2637 . 1 (d ) , Failure to submit the "Spill Container Testing Report Form" within 30 days XV ❑ R ❑ COS 2637 . 1 (e) 117 CCR 2637(e) , 2637(f) Failed to submit "Secondary Containment Testing Report Form" within 30 days after the test ❑ V o R ❑ COS 118 CCR 2637 . 2 (d &e) , Failure to submit the "Overfill Prevention Equipment Inspection Report Form" within 30 days ❑ V ❑ R ❑ COS 2665(a&b) 119 CCR 2663 , 2712(b)(6) Failure to comply with tank lining certification , testing , inspection , and record requirements ❑ V ❑ R ❑ COS 120 CCR 2631 , 2640 . 1 , Failure to submit and/or maintain documentation regarding compatibility for UST system components ❑ V ❑ R ❑ COS 2665 , 2711 FA0006439 PR0231070 SC001 01 /18/2023 EHD 23-01 Rev, 12/06/2021 Page 1 of 4 Underground Storage Tank Program OIR 1868 E . Hazelton Avenue Stockton , California 95205 1 T 209 468-3420 1 F 209 464 -0138 1 www . sjgov. org/EHD