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San Joaquin County <br /> 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 /> QLtkoR�'� <br /> Underground Storage Tank Program Service Request Inspection Report <br /> Facility Name and Address: ARCO 07049, 800 E Kettleman LN , LODI 95240 <br /> NEEDED: In addition,the following information must be submitted within 30 days after the UST removal date(7/16/19): <br /> 1) Analytical results: only results that come directly from a third-party California certified laboratory with affixed chain of <br /> custody 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 /> Received by: Name and Title: Ian Treat, Project Professional-Ante <br /> EH Specialist: SHEWIT WOLDEAREGAY Phone: (209)468-0216 <br /> FA0003633 SR0080535 SC134 07/16/2019 <br /> EHD 23-01 Rev.06/30/15 Page 2 of 2 Underground Storage Tank Program Service Request Inspection Report <br />