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SAN JOAQUIN COUNTY <br /> w ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.oro/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Pilot Travel Center, LLC April 28, 2017 <br /> Facility Address: Service Request#: <br /> 1501 North Jack Tone Road, Ripon, CA 95366 SR0076380 (Addendum) <br /> Onsite Service Technician's Name: ICC Service Technicianlinstaller Exp.Date: Manufacturer Training: <br /> James Blaine 7/14/2018 Incon 9/29/2018 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> 13 mechanical Model: <br /> ❑ ❑ ❑ 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: <br /> ❑ ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑fail safe Serial#: p <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑positive shutdown Model: Satellite#22 UDC(s) Piping <br /> ❑fail safe Serial#: T5-91 STP Sump(S) UST(s) <br /> ❑NA <br /> sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: October 2017 <br /> ❑fail safe Serial#: Note: Please be aware that 20 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 /> On site to witness secondary containment testing of the underground storage tank, T-5 premium <br /> unleaded submersible turbine pump (STP) sump and the satellite under dispenser containment (UDC) <br /> No. 22 sump. The satellite UDC No. 22 and the T-5 premium unleaded STP sumps passed the <br /> fifteen-minute Incon tests. This UST facility is approved to operate. Testing for the satellite UDC No. <br /> 22 and T-5 premium unleaded STP sumps are next due in October 2017. <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe Received By: Title: <br /> %LAO I eYV <br /> EHD 23-04 Rev.04/19/12 UST SERVICE REQUEST INSPECTION REPORT <br /> 9171 9690 0935 0152 0946 57 <br />