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SAN JOAQUIN COUNTY <br /> I + ENVIRONMENTAL_ HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Rancho San Miguel Market Thursday, June 14, 2012 <br /> Facility Address: Service Request#: <br /> 1427 Airport Way, Stockton obtain within 1 business day <br /> Onsite Service Technician's Name: ICC Service Technicianlinstaller Exp.Date: Manufacturer Training: <br /> Randy Wilkerson 15/9/13 VR x. 318/14 <br /> SERVICE SERVICE <br /> Leak detector <br /> Spill bucket [I minimum 5 gallon <br /> El mechanical Model: <br /> ❑ ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> C3mechanical Model: <br /> © ❑ electronic Serial#: El 1 hour hydrostatic ❑ Incon TS-STS <br /> 1:1 line test programmed <br /> ❑ Caldwell System [I Other <br /> A F11 [, sensor <br /> ❑ positive shutdown Model: VR 794380-208 Primary piping testing at: <br /> E] psi <br /> ❑x fail safe Serial#: 922621 mimi <br /> ❑ NA nutes <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 he aware that 21 containment components are required to he 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 LG letter 150-1) ❑ Other: see below <br /> 0 This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> The 91 fill sump sensor was replaced at the time of the annual monitoring system certification. <br /> Witnessed functionality testing of sensor, including fail safe and sensor out. Passed. <br /> "Obtain a permit from the EHD for this work within one business day. If a permit is not obtained <br /> within one business day, a "Failure to Obtain a Permit" penalty will apply. <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received y: Title: <br /> EHD 23-04 Rev.0 2 UST SERVICE REQUEST INSPECTION REPORT <br />