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Time In: <br /> Time Out: <br /> opQ.�tN. San Joaquin County <br /> .X Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • �... P Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sigov.org/ehd <br /> �<<FORtN <br /> Underground Storage Tank Program Service Request Inspection Report <br /> Name of Facility: FLYING J TRAVEL PLAZA#618* Date: 01/03/2020 <br /> Address: 1501 N JACK TONE RD , RIPON 95366 <br /> Requestor: JONES COVEY GROUP, INC Telephone: <br /> Program Element: 2304-UST REMOVAL Request#: SR0081075 <br /> Inspection Type: 134-UST REMOVAL INSPECTION <br /> Onsite Service Technician: Sampler-Paul Supple ICC Service Tech/Installer Exp. Date: <br /> Manufacturer training: <br /> OVERALL INSPECTION NOTES AND COMMENTS <br /> NOTES <br /> On site for the following: <br /> -Sampling was conducted by Broadbent. <br /> -Sampler: Paul Supple <br /> -Two samples, one at each end was taken into native soil below the tank, labeled T1 and T2. (Total of 4 tank soil samples <br /> were taken from the tank pit). The soil samples obtained from the tank were described to be a sandy soil. The soil samples <br /> beneath the tank were obtained with an excavator. Samples were collected at a depth of 15 ft. Groundwater and slap was not <br /> observed during excavation. <br /> -Soil stockpile : approximately 123 cubic yards <br /> -Two stockpile samples were taken, labeled SP1 and SP2. (Total of 4 soil samples were taken from the stockpile) <br /> -No noticeable staining or discoloration was observed.The sampler stated no odor was found. <br /> -Discussed sampling and analytic requirements with sampler, referencing the sampling protocols approved in the permit.. <br /> NOTE: In addition,the following information must be submitted within 30 days after the UST removal. <br /> 1)Analytical results: only results that come directly from a third-party California certified laboratory with affixed chain of custody <br /> will be accepted by EHD. <br /> 2) UST tracking Record Sheet and/or Tank and Piping Hazardous Waste Manifest Tank Closure Certification Form (DTSC <br /> Form 1249) <br /> 3) Hazardous Waste Manifest for rinsate and residual product, disposal records for piping, spill containers and sumps. <br /> 4) Backfill Excavation Certification <br /> The person in charge is responsible for ensuring that the above mentioned facility is in compliance with all applicable sections of the California Health and <br /> Safety Code.If a reinspection is required,fees will be assessed at the current hourly rate. <br /> 694 <br /> Received by: U Name and Title: Paul Supple, Project Manager <br /> EH Specialist: SHEWIT WOLDEAREGAY Phone: (209)468-0216 <br /> FA0006672 SR0081075 SC134 01/03/2020 <br /> EHD 23-01 Rev.06/30/15 Page 1 of 1 Underground Storage Tank Program Service Request Inspection Report <br />