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O PaU1N. C , <br />SAN JOAQUIN COUNTY <br />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 />�qC%FpR�`P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />Safeway <br />Tuesday, July 20, 2010 <br />Facility Address: <br />Service Request #: <br />1987 W 11th St Tracy CA <br />SR0060366 <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />Michael Briggs <br />8033115 -UT 6/23/11 <br />VMI 2429 8/11 V/R B38235 <br />SERVICE <br />SERVICE <br />Leak detector <br />El mechanical Model: <br />Spill bucket ❑ minimum 5 gallon <br />E] <br />11 electronic Serial #: <br />El❑ <br />1 hour hydrostatic ❑Incon TS -STS <br />❑ Caldwell System ❑ Other <br />❑ line test programmed <br />Leak detector <br />Spill bucket ❑ minimum 5 gallon <br />El <br />❑ mechanical Model: <br />ElEl1 <br />hour hydrostatic ❑Incon TS -STS <br />11 electronic Serial #: <br />11 Caldwell System 11 Other <br />11 line test programmed <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 programmed <br />sensor <br />❑ positive shutdown Model: <br />El <br />Primary piping testing at: <br />El <br />❑ fail safe Serial #: <br />psi <br />minutes <br />11 NA <br />sensor <br />Secondary containment testing for: <br />❑ <br />❑ positive shutdown Model: <br />UDC(s) Piping <br />❑ fail safe Serial #: <br />Sump(s) 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 21 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 />❑x <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 />EHD <br />Revi <br />Verified functionality of all sensors, power out, and sensor out. Verified 4 PLLD's will detect a leak at <br />3.Ogph at 10 psi. Verified overfill prevention mechanism Audio/Visual set at 90%. OK to operate at <br />this time. <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT H URLY RATE. <br />EHD Ins Receiv y: - FiNe--- <br />./ 71 <br />Z3 UST9&-'VICE REQUEST INSPECTION REPORT <br />0 1110 <br />10 <br />Vr <br />