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Page 1 of 5 San Joaquin County Environmental Health Department 1868 East Hazelton Avenue, Stockton, California95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www sigoy orglehd Underground Storage Tank Program Inspection Report Facility Phone: Date: Facility Name: CERS to: Facility Address: Inspection Contact: Title: Phone: ion T Inspection ype: Program: Consent For: Consent Given By: Inspection Photos Samples Exp. Date: Designated Operator: Ex Date: P Service Technician Onsite: Service Technician Manufacturer's Training COR = California Code of Regulations H5C = Health and 5 ety mn Ul ii = Gotle of Federal Regulations V = Violation R = Repeal violation COS = Corrected on site during inspection File Review ❑ V ❑ R ❑ COS 101 HSC 25284 No permit to operate 102 HSC 25284(a)(3) No written agreement between tank owner and tank operator to monitor the tank system ❑ V ❑ R ❑ COS 103 HSC 25292.2 Current financial responsibility documents not submitted ❑ V ❑ R in COS 104 CCR 2711 UST Operating Permit Application for Facility and Tank information not submitted or current ■ V ❑ R ❑ COS 105 HSC 25286(c) Current BOE number not submitted ❑ V o R ❑ COS not current or approved by the EHD ■ V ❑ R ❑ COS 106 CCR 2632 Monitoring and response plans 107 CCR 2632(d)(1)(C) Plot plan/site map not submitted or failed to completety show where monitoring is performed ❑ V ❑ R ❑COS 108 CCR 2637(f), 2638(e) Failed to notify the EHD 48 hours prior to conducting testing ❑ V ❑ R ❑ COS 109 CCR 2637 Failed to test secondary containment ❑ V ❑ R ❑ COS 110 CCR 2637(e) Failed to submit secondary containment test report within 30 days ❑ V ❑ R ❑ COS 111 CCR 2638(a) Failed to test monitoring and leak detection equipment annually ❑ V ❑ R ❑ COS 112 HSC 25284.2 Failed to test spill containers annually ❑ V ❑ R ❑COS 113 CCR 2638(d) Failed to submit monitoring system certification test report within 30 days ❑V ❑R ❑COS 114 CCR 2636(f) Failed to perform 0.1 gph annual line test for pressurized piping without fail safe or shut down ❑ V ❑ R ❑COS 115 CCR 2715(a) Failed to inform the EHD of a change of designated operator within 30 days ❑ V ❑ R ❑COS service tech or installer did not possess current ICC certification ❑ V ❑ R ❑COS 116 CCR 2715 Designated operator, 117 HSC 25292.5 Failed to conduct ELD testing on a system located within 1 000'of a public well ❑V oR oCOS 118 HSC 25292.5 Failed to repair and retest system due to failed ELD test ❑V ❑R ❑COS 119 CCR 2644.1(a)(5) Failed to submit ELD test results within 60 days ❑ V ❑ R ❑COS lined or repaired steel tank within 10 years of lining and every 5 years after ❑ V ❑ R ❑ COS 120 CCR 2663 Failed to inspect a 121 CCR 2663 Failed to submit tank lining certification within 30 days or to conduct proper tests ❑ V ❑ R ❑COS HSC 25299 Documents were falsified or misrepresented ❑V o ❑COS 122 123 CCR 2661 Permit to repair UST system not obtained P a V ❑ R ❑COS 124 CCR 2635(d) Failed to submit UST Certification of Installation/ odification ❑V ❑R ❑COS 125 CCR 2712(f) Failed to submit a written response within 30 days of receiving an inspection report ❑ V ❑ R ❑ COS Phone: Date: Received by Ins ctor: Pe 'I i �� (initial):bk - Page 1 of 5