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>.•.tri SAN JOAQUIN COUNTY <br /> r.� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> q� P, <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> 1 6)i <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Food Mart Gasoline Thursday, October 22, 2015 <br /> Facility Address: Service Request#: <br /> 85 E. Fremont St. SR0073279 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> nris Adams 12!12/15 VMI 1/30/16 <br /> SERVICE SERVICE <br /> 1 ? Leak detector Spill bucket ❑ minimum 5 gallon <br /> I� mechanical Model:VMI 99 LD-2000 <br /> � ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: 15081366 ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑fail safe Serial#: minutes <br /> ❑ NA <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 21 containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every 36 months thereafter. <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 /> Onsite to witness testing of 87 mechanical line leak detector- passed <br /> THIS FACILITY IS SUBJECT TO REI NSPECTIO ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> Receive B Titl <br /> EHD Inspector: al Y .—� <br /> IhL� �j <br /> rt <br /> EHD 23-04 Rev.04/19/12 UST SERVICE REQUEST INSPECTION REPORT <br />