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PSluliy <br /> SAN JOA U l N Environmental Health Department <br /> COUNTY <br /> rtir Greatness grows here. <br /> OFFICIAL INSPECTION REPORT <br /> FACILITY NAME/TYPE: Lodi Memorial Hospital DATE. 11/16/2021 <br /> ADDRESS:975 S. Fairmont Ave CITY: Lodi ZIP CODE:95240 <br /> OWNER/OPERATOR:Adventist Health Lodi Memorial Hospital TELEPHONE#:(209) 334-3411 <br /> --F <br /> TYPE OF INSPECTION: ❑ COMPLAINT ❑ CONSULTATION W OTHER PROGRAM 2351 RECORD PR0231331 <br /> ELEMENT: ID#: <br /> NATURE OF COMPLAINT/CONSULTATION: <br /> On site to witness the routine line integrity test. <br /> OBSERVATIONS/COMMENTS: <br /> Witnessed line testing for the diesel product line using the Petro Tite line tester. <br /> Diesel line was tested and passed. <br /> Service Technician Onsite: Zane Nimmo <br /> ICC: 05/26/23, Tank Tester: 03/31/22, Petro Tite: 03/04/22 <br /> CORRECTIVE ACTIONS: <br /> Submit a copy of the test results to the Environmental Health Department within 30 days. <br /> CORRECT BY: <br /> INSPECTED BY:Vicky Vang-Lee <br /> RECEIVED BY: Emailed to Timothy Duncan @ duncant@ah.org DATE: 11/16/2021 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 48-05 Rev.05/21/18 INSPECTION REPORT <br />