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x �'•p SAN JOAQUIN COUNTY <br /> j ENVIRONMENTAL HEALTH DEPARTMENT <br /> ;. 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.ora/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Waterloo Food & Fuel Monday, July 19, 2010 <br /> Facility Address: Service Request : <br /> 3030 E. Waterloo, Stockton, CA 95205 SR0060405 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> Bryan Mitchell (Donlee Pump) 5293476-UT 5/28/2012 FMS:lnstall (2012);Progrm (2012 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑ electronic Serial#: ❑ ❑1 hour hydrostatic 13 Incon TS-STS <br /> ❑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 /> 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 /> 87 Annul sensor Primary piping testing at: <br /> ❑positive shutdown Model: Incon TSP-EIS ❑ p <br /> si <br /> 0 fail safe Serial#:64005 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 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% ❑X 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 /> Observed sensor functionality verification including positive shutdown, sensor out, and fail safe after <br /> replacement of monitoring panel replacement with a new TS-1001 ATG (S/N 59447), and TS-ROM <br /> Relay Output Module. All passed except 87 octane annular sensor. Wayne and Gavim of HMC <br /> replaced the defective sensor with a new Incon annular TSP-EIS annular sensor on an emergency <br /> repair basis. Observed functionality and fail safe verification of the replaced 87 octane annular <br /> sensor. Passed. Submit a permit application of the emergency repair to EHD within 24 working <br /> hours of replacement. Submit Certification of Modification (Form C) to EHD by 8/20/2010. <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT MY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins ctor 7Received By: Title <br /> EHD 2304 V men UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 06101110 <br />