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0o,.4�IH. c <br /> SAN JOAQUIN COUNTY <br /> Q: a ENVIRONMENTAL HEALTH DEPARTMENT <br /> N: < <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> . Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sioov.org/ehd <br /> �h <br /> 4�tFORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Arch Arco AM PM Monday, October 24, 2011 <br /> Facility Address: Service Request#: <br /> 4855 S. Hwy 99, Stockton SR0063420 <br /> Onsite Service Technician's Name: ICC Service Tachnicianllnstaller Exp.Date: Manufacturer Training: <br /> Gabriel Garcia 7/14/12 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ 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 /> ❑ mechanical Model: <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: ElPrimary S piping testing at: <br /> ❑fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: 17/18 UDC(s) Piping <br /> ❑fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑x Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑fail safe Serial#: NotePlease b aware that P mr tnmem mmmnents are rewuir to b tested upon <br /> ❑ NA installation,6 months alter,and every 36 months Memalter <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 /> Witnessed secondary containment testing of the UDC 17/18 sump with a Caldwell tester for 30 <br /> minutes. Passed. <br /> THIS FACILITY BJECT TO REINSPECTION AT ANY T!ME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins r. I, Re - Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/09/10 <br />