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SA N �o AQ u I N Environmental Health Department <br /> C Q U N T Y Time In: <br /> _ Time Out: <br /> Greatness grows here, <br /> Underground Storage Tank Program Service Request Inspection Report <br /> Name of Facility: MY MINI MART Date: 04/30/2021 <br /> Address: 1756 N WILSON WAY, STOCKTON 95205 <br /> Requestor: DEBORAH JONES, ELITE IV CONTRACTORS Telephone: (209)461-6337 <br /> Program Element: 2308-UST RETROFIT Request#: SR0083505 <br /> Inspection Type: 298-UST RETROFIT REPAIR INSPECTION <br /> Onsite Service Technician: Micheal Kennard ICC Service Tech/Installer Exp. Date: 04/02/2022 <br /> Manufacturer training: OPW, 05/23/21 <br /> OVERALL INSPECTION NOTES AND COMMENTS <br /> NOTES <br /> On site for the following inspections on the 91 Tank <br /> -Spill container test: <br /> -Verified 5 gallon capacity and one hour hydrostatic test. <br /> -Verified proper drainage <br /> -Secondary containment test on 91 tank <br /> All passed. <br /> Overfill prevention verification: Drop tube measurement <br /> -NOT replaced,the Service Technician stated that they did not have to replace the drop tube and that it was included in the <br /> scope of work just in case it got damaged.An amended scope of work is required to be submitted to EHD as soon as <br /> possible. <br /> This facility is approve to receive fuel in the 91 tank. <br /> To minimize person to person contact EHD is choosing to write the name of person receiving the report instead of having them <br /> sign. <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: Micheal kennard, Service Technician <br /> EH Specialist: PAUL NSO Phone: (209)616-3049 <br /> FA0001858 SR0083505 SC298 04/30/2021 <br /> EHD 23-01 Rev.09/16/2020 Page 1 of 1 Underground Storage Tank Program Service Request Inspection Report <br />