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Pa�IH <br /> �••" c $AIV.IOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> '. <br /> - Telephone: (209)468-3420 Fax:(209) 468-3433 Web:www.sigov.orglehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 7 Eleven Store #14117 D12237 Friday, September 2, 2011 <br /> Facility Address: Service Request#: <br /> 2725 Country Club Blvd., Stockton SR0063324 <br /> Onsite Service Technician's Name: ICC Service Technicianlinstaller Exp.Date: ManufacturerTraining: <br /> Jessie Wadkins 5112/13 512113 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ El1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑—1hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA ❑sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑fail safe Serial #: Note Please be aware that 21 containment components are required lobe tested upon <br /> ❑ NA installafion,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 LG letter 150-1) ❑ Other: see below <br /> ❑x This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> Onsite to witness sensor functionality verification after cold start of monitoring panel. Verified fail safe <br /> and sensor out. Passed. <br /> THIS (FACILITY I JECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspec Received By: Title: <br /> UST SERVICE REQUEST INSPECTION REPORT <br /> EHD 2304 <br /> Rev 10106110 <br />