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SR0081813
EnvironmentalHealth
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12 (STATE ROUTE 12)
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13550
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4200/4300 - Liquid Waste/Water Well Permits
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SR0081813
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Last modified
11/19/2024 3:48:04 PM
Creation date
8/11/2020 2:27:35 PM
Metadata
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EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
SR0081813
PE
4201
FACILITY_NAME
JOE GRINDSTONE ASSOCIATION
STREET_NUMBER
13550
STREET_NAME
STATE ROUTE 12
City
LODI
Zip
95242
APN
05502002
ENTERED_DATE
2/26/2020 12:00:00 AM
SITE_LOCATION
13550 HWY 12
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
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EHD - Public
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APPENDIX E <br />Tank Instaiiation Checklist <br />TO INSTALLER: After tank installation, deliver the Installation Manual with the completed Tank Installation Checklist to the tank owner. Retain a copy <br />of each for your records. <br />TO OWNER: After installation, retain the limited warranty, the Installation Manual and completed Tank Installation Checklist for future reference and to <br />facilitate any warranty claim. <br />INSTALLATION DATE(S): <br />INSTALLATION ADDRESS: <br />PERSON COMPLETING FORM: <br />TANK INFORMATION <br />TANK #1 <br />TANK #2 <br />TANK #3 <br />TANK #4 <br />Tank type—Single-Wall (SW), Double -Wall (DW) <br />Monitoring fluid visible on exterior of tank—yes or no <br />Tank Usage (Fuel)—Fuel, DEF, Pipeline Sump <br />Requirements met for double-wall tanks shipped under interstitial <br />vacuum—yes or no <br />Tank Usage (Water)—Potable Water, Water Collection <br />Record fluid level in reservoir for double-wall wet tanks <br />Tank Usage (Wastewater)—Grease Interceptor, Septic, <br />Industrial Wastewater/Chemical <br />If required, tank passed pressure/soap test—yes or no <br />Tank Usage (Oil/Water Separator) <br />Nominal Tank Diameter—give in feet <br />Nominal Tank Capacity—give in gallons or liters (and note which) <br />If applicable, ULIULC #(read from tank label)—yes or no <br />SITE INFORMATION (See section 1) <br />TANK #1 <br />TANK #2 <br />TANK #3 <br />TANK #4 <br />Primary backfill meets Appendix C requirements—yes or no <br />Monitoring fluid visible on exterior of tank—yes or no <br />Secondary backfill material will be used—yes or no <br />Requirements met for double-wall tanks shipped under interstitial <br />vacuum—yes or no <br />Secondary backfill meets our requirements—yes or no <br />Record fluid level in reservoir for double-wall wet tanks <br />Geotextile will be used—yes or no <br />If required, tank passed pressure/soap test—yes or no <br />Excavation—shored or not shored <br />Tank will see traffic loads (H20 or HS20)—yes or no <br />Hole condition—dry or wet <br />Anchoring system will be used—yes or no <br />If applicable, anchoring system used—deadmen or anchor slab <br />JPREINSTALLATION INSPECTION AND TESTING (See sections 3 and 4) TANK #1 TANK #2 TANK #3 TANK #4 <br />_ Shipping damage—yes or no <br />_ Loss of vacuum—yes or no <br />Monitoring fluid visible on interior of tank—yes or no <br />Monitoring fluid visible on exterior of tank—yes or no <br />Requirements met for double-wall tanks shipped under interstitial <br />vacuum—yes or no <br />Record fluid level in reservoir for double-wall wet tanks <br />If required, tank passed pressure/soap test—yes or no <br />Ne>a PULE <br />ZCL' XERXES' 45 <br />
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