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OAQUI/y C <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.segov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Valley Pacific Charter Way Cardlock Monday, April 16, 2012 <br /> Facility Address: Service Request#: <br /> 1501 W. Charter Way, Stockton SR0064605 <br /> Onsite Service Technician's Name: ICC Service TechniciaMnstailer Exp.Date: Manufacturer Training: <br /> Fred Babel ix. 7/7/12 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑electronic Serial#: <br /> ❑line test r rammed D Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑electronic Serial#: ❑Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> ❑ ❑ positive shutdown Model: El psi piping testing at: <br /> ❑fail safe Serial#: p <br /> ❑ NA minutes <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 /> rEl <br /> Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> Overfill prevention(see LG letter 150-1) ❑x Other: see below <br /> ❑X This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> On site to witness functionality verification testing of the float and chain in the #7 satellite UDC. <br /> Passed. <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD Inspector: cei By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />