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°t4ufK c 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 /> 4�1FORa <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Escalon Mini Mart Monday, June 4, 2012 <br /> Facility Address: Service Request i#: <br /> 1097 Yosemite Avenue, Manteca SRoo 62373 <br /> Onsite Service Technician's Name: ICC Service TechniciaMnstailer Exp.Date: Manufacturer Training: <br /> Kirk m Masten <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑electronic Serial#: El 1 hour hydrostatic D Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System D Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑❑electronic Serial#: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> D line test ro rammed ❑Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑x psi <br /> D fail safe Serial#: minutes <br /> D 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 /> D NA installation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> EDDrop tube with mechanical overfill at 95% ElCorrosion protection <br /> Overfill prevention(see LG letter 150-1) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate N This UST facility is NOT APPROVED to operate <br /> Witnessed primary containment test performed ;50 psi for 1 hr) - Passed <br /> Set up lake test on all the UDC and left for 24hr. Level will becheckedtomorrow. <br /> v D w �I VE,4A C� 3.r &k I e c.c�C Lea.,n <br /> P d v� <br /> , � r Vw <br /> u � wvU G< a cc <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: <br /> EHD 2304 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />