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SAN N O Q Q U I N Environmental Health Department O II II NN Y Underground Storage Tank Program Inspection Report Facility Name: Facility Phone: Date: U ZL G r,Q C�'Y tv► S L I- L SJ l NINE ' Z u Facility Address: CERS ID: 43 InsTitle: Phone: pection Contact: ( '1. 0111 jGtMSSe h Gt vtiir�t � j1'l � v>^ � �,r Zoe .2 > S c SS" I spection Type: Program: , Consent For: Consent Given By: Q �"'/ f ©'fns ection E Photos ElSamples R ) L 54 V j �t m �tvti� � �^ + clltWIN S � I Service Technician Onsite: Exp. Dat : Designated Operator:, Exp. ate: C. W , �, I �Ic- ✓ 3o , Zc2a_fu I,.,+ � 1Gili u4Pi } S rvice Technician Manuf cturer's Training : . TslovvjrW 1h0lsse� ' (LZI � ' G �Iw u1f r � � Z � .= ) JA4I CCR = Title 23 California Code of Regulations HSC = Health and Safely Code CFR = Code of Federal Regulations EHD = Environmental Health Department MENOMONEE V = Violation R = Repeal violation COS = Corrected on site during inspection File Review 101 HSC 25284; CCR Failure to obtain a permit to operate from the EHD including but not limited to unpaid permit fees D V D R D COS 2711 (d) 102 CCR 2711 Failure to submit a complete and accurate application for a permit to operate a UST D V D R D COS 103 CCR 2635(f) , 2636(c)(2) Failure to submit the UST Certification of Installation/Modification D V o R D COS 104 CCR 2632(d) (1 ) , Failure to submit a complete and accurate UST Monitoring Plan D V n R D COS 2634(d) 105 CCR 2632(d) (2) , Failure to submit a complete and accurate UST Response Plan OV o R D COS 2634 (e) 106 CCR 2632(d) , 2641 (h) Failure to submit and maintain a current facility plot plan / site map D V D R D COS 107 HSC 25292 .2; CCR Failure to submit and maintain complete and current financial responsibility documents XV qR D COS 2711 (a) (11 ) 108 CCR 2620(b) ; HSC Failure to implement or maintain a written agreement between the UST owner and operator n V D R D COS 25284 (a) (3) 109 CCR 2715(a) (1 ) (B) , Failure to submit " Designated Underground Storage Tank Operator Identification Form" within 30 days D V D R D COS 2715(a) (3) 110 CCR 2715(a) (1 ) (A) , Failure to submit the "Underground Storage Tank Statement of Understanding and Compliance Form" D V D R o COS 2715(a) (2) 111 CCR 2637 , 2638(e) , Failed to notify the EHD 48 hours prior to conducting testing o V D R D COS 2643(g) 112 CCR 2638 , 26410) , Failure to have properly qualified service technician test leak detection equipment every 12 months o V D R D COS 2715(f) 113 CCR 2637(a-d) , 2712(b) Failure to conduct secondary containment testing D V D R D COS (1 ) (F) 114 CCR 2636 (f) (3) , 2643(c) Failure to perform line integrity test every 12 months or within 30 days of repair of primary pipe o V D R o COS (3) 115 CCR 2638(c) , 2638(d) Failure to submit "Monitoring System Certification Form" within 30 days of completion of the test o V D R D COS 116 CCR 2637 . 1 (d) , Failure to submit the "Spill Container Testing Report Form" within 30 days D V D R D COS 2637. 1 (e) 117 CCR 2637(e) , 2637(f) Failed to submit "Secondary Containment Testing Report Form" within 30 days after the test n V o R D COS 118 CCR 2637.2(d&e) , Failure to submit the "Overfill Prevention Equipment Inspection Report Form" within 30 days D V D R D COS 2665(a&b) 119 CCR 2663 , 2712(b)(6) Failure to comply with tank lining certification , testing , inspection , and record requirements D V o R D COS 120 CCR 2631 , 2640. 1 , Failure to submit and/or maintain documentation regarding compatibility for UST system components n V D R D COS 2665 , 2711 Page 1 of 4 Underground Storage Tank Program OIR 1868 E . Hazelton Avenue I Stockton , California 952051 T 209 468-3420 1 F 209 464-0138 1 www . sjgov. org/EHD