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6 0 <br />--��` . 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.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />TRACY SHELL <br />SEPTEMBER 2, 2016 <br />Facility Address: <br />Service Request #: <br />3725 NORTH TRACY BLVD. TRACY, CA <br />SR0075353 <br />Onsite Service Technician's Name: <br />ICC Service Technician/installer Exp. Date: <br />Manufacturer Training: <br />RANDY WILKERSON <br />1 APRIL 24, 2017 <br />1 VEEDER ROOT MAY 11, 2017 <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 />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑X <br />sensor <br />❑ <br />❑ positive 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 LG letter 150-1) <br />❑X This UST facility is APPROVED to operate <br />SERVICE <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 />❑ <br />❑ 1 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 20 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 />❑X <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />On site to witness functionality of the 91 -product submersible turbine pump (STP) sump liquid sensor <br />208 after replacement of the 91 -product turbine relay. Observed positive shutdown of the 91 -product <br />turbine when the 208 sensor was placed in water. The test passed. <br />I THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIMIE AT EHD'S CURRENT HOURLY RATE. I <br />p Received By: Title <br />EHD Ins a �r!r''// <br />EHD 23-04 Rev. 04/19/12 1 1 UST SERVICE REQUEST INSPECTION REPORT <br />