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Environmental Health DepartmentFacility Name:Super Store Industries - Grocery DivisionFacility Address:16888 McKinley Ave, Lathrop, CA 95330Facility Phone:(209) 858-2010Program:2361 - UST FACILITYInspection Type:ROUTINE INSPECTION - Operating PermitDate:October 12, 2020CERS ID:10166883Inspection Contact:Jamie Lima Consent For: Consent Given By:Troy Embry, Facilities SupervisorTitle:Environmental ContactPhone:(209) 540-8791InspectionPhotosSamplesUnderground Storage Tank Program Inspection ReportService Technician Manufacturer's Training:VR, 07/08/22; VMI, 11/12/21; OPW,03/13/22Service Technician Onsite:Felix RamirezExp. Date:11/07/2020 Designated Operator:Troy EmbryExp. Date:01/12/2022HSC= Health and Safety CodeCFR= Code of Federal RegulationsCCR= Title 23 California Code of RegulationsR= Repeat violationCOS= Corrected on site during inspectionV= ViolationFile Review101□ V □ R □ COSFailure to obtain a permit to operate from the EHD including but not limited to unpaid permit feesHSC 25284; CCR 2711(d)102■ V □ R ■ COSFailure to submit a complete and accurate application for a permit to operate a USTCCR 2711103□ V □ R □ COSFailure to submit the UST Certification of Installation/ModificationCCR 2635(f), 2636(c)(2)104□ V □ R □ COSFailure to have an approved UST Monitoring PlanCCR 2632(d)(1), 2634(d)105□ V □ R □ COSFailure to have an approved UST Response PlanCCR 2632(d)(2), 2634(e)106□ V □ R □ COSFailure to submit and maintain a current facility plot plan / site mapCCR 2632(d), 2641(h)107■ V □ R ■ COSFailure to submit and maintain complete and current financial responsibility documentsHSC 25292.2; CCR 2711(a)(11)108□ V □ R □ COSFailure to implement or maintain a written agreement between the UST owner and operatorCCR 2620(b); HSC 25284(a)(3)109□ V □ R □ COSFailure to submit "Designated Underground Storage Tank Operator Identification Form" within 30 daysCCR 2715(a)(1)(B), 2715(a)(3)110□ V □ R □ COSFailure to submit the "Underground Storage Tank Statement of Understanding and Compliance Form"CCR 2715(a)(1)(A), 2715(a)(2)111□ V □ R □ COSFailed to notify the EHD 48 hours prior to conducting testingCCR 2637, 2638(e), 2643(g)112□ V □ R □ COSFailure to have properly qualified service technician test leak detection equipment every 12 monthsCCR 2638, 2641(j), 2715(f)113□ V □ R □ COSFailure to conduct secondary containment testingCCR 2637(a-d), 2712(b)(1)(F)114□ V □ R □ COSFailure to perform line integrity test every 12 months or within 30 days of repair of primary pipeCCR 2636(f)(3), 2643(c)(3)115□ V □ R □ COSFailure to submit "Monitoring System Certification Form" within 30 days of completion of the testCCR 2638(c), 2638(d)116□ V □ R □ COSFailure to submit the "Spill Container Testing Report Form" within 30 daysCCR 2637.1(d), 2637.1(e)117□ V □ R □ COSFailed to submit "Secondary Containment Testing Report Form" within 30 days after the testCCR 2637(e), 2637(f)118□ V □ R □ COSFailure to submit the "Overfill Prevention Equipment Inspection Report Form" within 30 daysCCR 2637.2(d&e), 2665(a&b)119□ V □ R □ COSFailure to comply with tank lining certification, testing, and inspection requirementsCCR 2663, 2712(b)(6)120□ V □ R □ COSFailure to submit and/or maintain documentation regarding compatibility for UST system componentsCCR 2631, 2640.1, 2665, 2711FA0003833 PR0232523 SC001 10/12/2020EHD 23-01 Rev. 9/16/2020Underground Storage Tank Program OIRPage 1 of 51868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/EHD