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ORgUtN_ C <br />�'—�'�-oma SAN JOAQUIN COUNTY <br />r—�?T ENVIRONMENTAL HEALTH DEPARTMENT <br />W. ` 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone. (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.ora/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Dabs: <br />Quickstop <br />Friday, January 7, 2011 <br />Facility Address: <br />Service Request <br />1580 Main Street, Ripon <br />SR0061743 <br />Onsite Service Technician's Name: <br />ICC Service TechniciaMnstaller Exp. Date: <br />Manufacturer Training: <br />Lance Juarez ]Verified, <br />2/26/09 <br />B34636, 5/26/12 <br />SERVICE <br />SERVICE <br />Leak detector <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ electronic Serial #: <br />❑ Caldwell System ❑ Other <br />❑ line test programmed <br />Leak detector <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ electronic Serial #: <br />❑ Caldwell System ❑ Other <br />❑ line test programmed <br />sensor <br />Primary piping testing at: <br />El <br />[I positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />minutes <br />❑ NA <br />sensor <br />Secondary containment testing for: <br />❑ <br />❑ positive shutdown Model: <br />UDC(s) Piping <br />❑ fail safe Serial #: <br />Sump(s) UST(s) <br />❑ NA <br />❑ <br />Testing for the above components are next due by: <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />Note: Please be aware Bat 2^ containment componema are required m be tested upon <br />❑ NA <br />iistarawn. 6 montlts atter, and every 36 moMns mereafter. <br />❑ <br />Drop tube with mechanical overfill at 95% <br />® <br />Cold start of monitoring panel <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Corrosion protection <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />❑ <br />Other: see below <br />❑X <br />This UST facility is APPROVED to operate <br />❑ <br />This UST facility is NOT APPROVED to operate <br />Verified functionality of all sensors. The UDC had Bravo Float and Chain - not tested. Verified fail <br />safe and sensor out. All passed. <br />THIS FACILITY IS SUBJECT TO REI NSPE ON AT ANY ME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: R By: Title: — <br />EHD 23-04 I / / s� UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 I/ <br />