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Op4utN• C <br />.. SAN JOAQUIN COUNTY <br />.Z <br />Q• ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />�9�ikoae' i <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />SUPER CENTER MART <br />Wednesday, June 16, 2010 <br />Facility Address: <br />Service Request #: <br />701 E. CHARTER WAY, STOCKTON <br />SR0060174 <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />JOSEPH BARTHOLDI <br />06/23/10 04/09/11 <br />OPW= 08/12/10 <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />sensor <br />El11positive <br />shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LIS letter 150-1) <br />SERVICE <br />91 Spill bucket O minimum 5 gallon <br />❑X <br />211 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />—1 <br />❑ <br />ff hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note. Please be aware that 21 containment components are required to be tested upon <br />installation 6 months after, and every 36 months thereafter. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />ONSITE TO VERIFY ONE HOUR HYDROSTATIC TEST ON THE REPLACED (91) PREMIUM SPILL <br />CONTAINER. THE SPILL CONTAINER PASSED THE TEST. I ALSO WITNESSED THE SPILL <br />CONTAINER HOLD FIVE GALLONS AND VERIFIED THAT THE DRAIN VALVE IS OPERATIONAL. <br />A SECONDARY CONTAINMENT TEST ON THE ANNULAR SPACE OF THE UST HELD <br />PRESSURE AT 3 PSI FOR ONE HOUR. SUBMIT COPIES OF TEST RESULTS FOR SPILL <br />CONTAINER AND SECONDARY CONTAINMENT TESTS AS WELL AS A COMPLETED FORM C <br />FOR THIS PERMIT TO BE CONSIDERED COMPLETE. <br />THIS ITY I CT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD ct Re d By: r / TTitle: r / �, _ <br />EHD 2304 UST SERVICE REQUEST INSPECTION REP <br />Rev 06/01/10 <br />ORT <br />