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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sidov.org/ehd <br /> S�rFOaN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> West Lane Chevron October 18, 2016 <br /> Facility Address: Service Request#: <br /> 4747 North West Lane SR0075921 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> Michal Kennard 11/14/2016 / 10/15/2017 Phil-Tite 11/18/2017 <br /> SERVICE SERVICE <br /> Leak detector 87-octane Spill bucket Z minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ �❑ electronic Serial#: 0 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed El Caldwell System O Other <br /> Leak detector 91-octane Spill bucket 0 minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ � 9 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System Z Other <br /> ❑ line test programmed <br /> sensor <br /> E] ❑ positive shutdown Model: ElPrima Peiping testing at: <br /> si <br /> ❑fail safe Serial#: <br /> ❑ NA minutes <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 be aware that 2°containment components are required to be tested upon <br /> ❑ NA I installation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% ❑ I Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑Q Other: see below <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> On site to witness one-hour hydrostatic testing of the 87-octane middle tank and 91-octane tank spill <br /> containers for newly-installed Phil-Tite model 85100-1 buckets. Each spill container held five gallons <br /> of water and the 87-octane spill container passed the one-hour hydrostatic test; but the 91-octane spill <br /> container failed the one-hour hydrostatic test. Each spill container had a drain valve that worked <br /> properly. This facility is approved to operate the 87-octane middle tank. The 91-octane tank cannot <br /> receive fuel until the spill container passes the one-hour hydrostatic test. <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: <br /> EHD 23-04 Rev.04/19/12 UST SERVICE REQUEST INSPECTION REPGRT <br />