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0 <br /> .P4 U I N C <br /> SAN JOAQUIN COUNTY <br /> a. ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.siQov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Country Market Cardlock Friday, March 25, 2011 <br /> Facility Address: Service Request#: <br /> 1524 Fresno Ave., Stockton SR0062179 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> Josh Simmons 9/16/11 OPW x. 12/2/11 <br /> SERVICE SERVICE <br /> Leak detector DSI Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑x <br /> El electronic Serial#: El1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System D Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El El❑ electronic Serial#: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> E] El shutdown Model: ElPrima Primary testing at: <br /> si <br /> ❑ fail safe Serial#: <br /> minutes <br /> El NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: Note: Please be aware that 2°containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LIS letter 150-1) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> Verified corrosion protection for the direct bury spill container prior to backfilling <br /> Still needed: <br /> - Five gallon capacity verification <br /> - One hour hydrostatic testing (or equivalent) <br /> - Proper drainage verification <br /> - Secondary containment testing on the diesel UST <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In N_ctor: Received By: Titie: <br /> EHD 2304 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/ <br />