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�PgUlry C <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />N. 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s'gov.org/ehd <br />c4<ikoR��P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />Super Center Mart <br />Wednesday, March 16, 2011 <br />Facility Address: <br />Service Request #: <br />701 E. Charter Way, Stockton <br />SR0062051 <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />Joseph Bartholdi <br />7/7/12 <br />VR x. 1/17/13 <br />SERVICE <br />SERVICE <br />Leak detector <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ 1 hour hydrostatic ❑Incon TS -STS <br />❑ electronic Serial #: <br />❑ Caldwell System ❑Other <br />❑ line test ro rammed <br />Leak detector <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ 1 hour hydrostatic ❑Incon TS -STS <br />❑ electronic Serial #: <br />[I Caldwell System ❑Other <br />[I line test ro rammed <br />sensor <br />Primary testing at: <br />❑ <br />❑ positive shutdown Model: <br />E] <br />❑ fail safe Serial #: <br />psi <br />minutes <br />❑ NA <br />sensor <br />Secondary containment testing for: <br />❑ <br />❑ positive shutdown Model: <br />UDC(s) Piping <br />❑ fail safe Serial #: <br />Suril UST(s) <br />❑ NA <br />❑ <br />Testing for the above components are next due by: <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />Note Please be aware that 20 containment components are required to be tested upon <br />❑ NA <br />installation, 6 months after, and every 36 months thereafter. <br />❑ <br />Drop tube with mechanical overfill at 95% <br />Cold start of monitoring panel <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Corrosion protection <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />❑ <br />Other: see below <br />This UST facility is APPROVED to operate <br />❑ <br />This UST facility is NOT APPROVED to operate <br />Cold start of monitoring panel conducted at time of inspection. Witnessed verification of sensor <br />functionality, sensor out, and fail safe. All passed. <br />I THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />Title: <br />L <br />EHD 2304 v / UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />