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OPQUIfy C <br /> ?' +E SAN JOAQUIN COUNTY <br /> dry— ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> �q��F O•Ra�P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Arco AM PM #5450 Friday, November 4, 2011 <br /> Facility Address: Service Request#: <br /> 1617 W. Fremont St., Stockton SR0062200 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> Chris Bishop 15/14/12 VR x. 6/8/12 VMI x. 6/7/12 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5gallon <br /> nx ❑ mechanical Model:VR 848480-001 (w/Swiftcheck) <br /> ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> 0 electronic Serial#: 324998 <br /> ❑ line test ro rammed ❑ Caldwell System ❑Other <br /> 11 Leak detector <br /> ❑ mechanical Model:VR 848480-001 (w/Swiftcheck) Spill bucket ❑ minimum 5 gallon <br /> � El©electronic Serial#: 325006 El1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑Caldwell System ❑Other <br /> sensor <br /> ❑ positive shutdown Model: ElPrimaps piping testing at: <br /> E] <br /> ❑fail safe Serial#: 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% ❑ 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 /> According to the technician on site, a cold start was not performed. <br /> Witnessed positive shutdown on all STP, fill, annular, and UDC sensors, including fail safe and sensor <br /> out to verify functionality of the newly installed flow controllers. Passed. <br /> Witnessed testing of the 87 and 91 PLLDs at 3 gph at 10 psi. Passed. <br /> **Update and submit a copy of the "UST Monitoring Plan" for EHD approval. An approved copy will be <br /> returned for on site records. <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT IME OT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector Received By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />