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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: C-STORE W/76 FUEL ISLAND Date: 12/11/2019 <br /> Address: 141 E HARNEY LN , LODI 95240 <br /> Requestor: MEL HIGGINBOTHAM, PM DESIGN GROUP INC Telephone: (530)303-2814 <br /> Program Element: 2303-UST/PIPING INSTALLATION Request#: SR0079417 <br /> Inspection Type: 131 -UST INSTALLATION INSPECTION <br /> Onsite Service Technician: Mario Lucero ICC Service Tech/Installer Exp. Date: <br /> Manufacturer training: Xerxes, 08/27/21 <br /> OVERALL INSPECTION NOTES AND COMMENTS <br /> NOTES <br /> On site for the installation of new USTs: <br /> -20,000 gallon (regular)Xerxes double-walled fiberglass tank <br /> -8,000 gallon (premium)/12,000 gallon (diesel)Xerxes double-walled fiberglass split tank. <br /> -Inspected tanks for brine leaks. No leaks observed. <br /> -Inside of tanks was inspected by the contractor on site and stated to be clean and brine-free. <br /> -Verified the use of the manufacturer installation checklist at the time of inspection. <br /> -Verified presence of deadmen and use of anchor straps. <br /> -Verified use proper pea gravel backfill. <br /> -Witnessed tank set. <br /> -Verified the application of additional corrosion protection on all metal anchor components. <br /> -Witnessed backfilling of the tank pit and compaction of pea gravel. <br /> NOTE:Additional inspections are required. Refer to the approval letter dated December 5, 2019 for a list of inspections <br /> needed. <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: Mario Lucero, Service Tech <br /> EH Specialist: SHEWIT WOLDEAREGAY Phone: (209)468-0216 <br /> SR0079417 SC131 12/11/2019 <br /> EHD 23-01 Rev.06/30/15 Page 1 of 1 Underground Storage Tank Program Service Request Inspection Report <br />