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ot`q��N c <br />?•� �t'••o � SAN JOAQUIN COUNTY <br />a. ENVIRONMENTAL HEALTH DEPARTMENT <br />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 Date: <br />Waterloo Liquor <br />Tuesday, March 6, 2012 <br />Facility Address: <br />Service Request #: <br />2512 Waterloo ors 5 C0c,k m\ <br />SR0063566 <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />Joe Bartholdi (ICC 8017009) <br />S.T. 7/7/2012; Install 7/12/2013 <br />1 Bravo Gold 660076 exp12/17/12 <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑X <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />Q <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />❑ This UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑X <br />50 psi <br />60 minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note: Please be aware that 2° containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />Q <br />Other: see below <br />© This UST facility is NOT APPROVED to operate <br />Verified primary piping soap test (Permit Condition #3b) below the UDC at 50 psi for at least one hour <br />(technician has pressurized the lines beginning yesterday), and 24 hour hydrostatic test (Permit <br />Condition #3c) both UDC sumps (began yesterday morning. This inspection occurred at noon today). <br />Passed. <br />-- Dispenser (east) UDC sump: Bravo Model B8383-F3L-B SN#: 04623 <br />-- Dispenser (west) UDC sump: Bravo Model B8382-F2L-B SN#: 04622 <br />Sensor functionality, secondary piping soap test (if applicable) before concrete is poured, and <br />secondary containment test after the concrete is set for at least 48 hours are still required before <br />facility is approved to operate. <br />I THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. I <br />Title: r — <br />EHiS 23-0,k/// ( / UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 ( v <br />