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?4t'4 '•o <br /> 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.s"gov.org/"ehd <br /> rt��iFOR��P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Chevron Station Thursday, December 16, 2010 <br /> Facility Address: Service Request#: <br /> 4344 E. Waterloo, Stockton SR0061352 <br /> Onsite Service Technician's Name: ICC Service Techniciannnstaller Exp.Date: Manufacturer Training: <br /> Nick Harvey 5115738-UT 2/21/2011 1 Wayne Perry#42846 12/29/2010 <br /> SERVICE SERVICE <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 /> sensor <br /> ❑ ❑ positive shutdown Model: ❑ Primary S piping testing at: <br /> ❑fail safe Serial#: <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: #7/8 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: Reese 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 /> roDrop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> Overfill prevention(see LG letter 150-1) ❑ Other: see below <br /> ® This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> Observed 1-hour equivalent hydrostatic test of the repaired (Blueline electrical penetration boot) UDC <br /> for Dispenser#7/8 using Wayne Perry Enhancement Leak Detection System. Passed. Submit <br /> installation and test report to EHD within 30 days of this report. <br /> THIS FACILITY IS SUBJECT TO REI SPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Insp for Recei B Tale <br /> r � <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />