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PQM 1�. • <br /> ��'c°,� SAN.IOAQUIN 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 /> 4�IFOR� <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Escalon Mini Mart Monday, January 14, 2013 <br /> Facility Address: Service Request R: <br /> 1097 Yosemite Avenue, Escalon SR0066337 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> Jason Perry 2/19/13 Incon - 1/17/13 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑❑electronic Serial#: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑mechanical Model: <br /> ❑ ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> 87 PIPING sensor <br /> ❑ 0 positive shutdown Model: LS3A Autostik JrElPrima PS piping testing at: <br /> X 9 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 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 /> Verified functionality - passed <br /> Verified sensor out and positive shutdown - passed <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: <br /> jA I I <br /> EHD <br /> 23-04 Rev.04/19/12 UST SERVICE REQUEST INSPECTION REPORT <br />