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°R4ul <br /> E SAN JOAQUIN COUNTY <br /> 1 SFr 4 .c <br /> c Za ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue , Stockton , CA 95205-6232 <br /> bee Telephone: (209) 468-3420 Fax: (209) 468-3433 Web : www . sigov. org/ehd <br /> qL / F0 <br /> UNDERGROUND STORAGE TANK ( UST ) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date : <br /> Arch Arco AM PM Monday , May 9 , 2022 <br /> Facility Address : Service Request #: <br /> 4855 S . Hwy 99 , Stockton SR0085021 <br /> Onsite Service Technician' s Name: ICC Service Tech niclan/I nstal ler Exp, Date : Manufacturer Training : <br /> Mike Kennard 7/6/23 OPW 5/ 19/23 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El 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 /> ❑ El 1 hour hydrostatic ❑ Incon TS - STS <br /> ❑ electronic Serial # : <br /> El line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at : <br /> ❑ ❑ positive shutdown Model : ❑ psi <br /> ❑ fail safe Serial #: <br /> 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 20 containment components are required to be tested upon <br /> ❑ NA installation, 6 months after, and every 36 months thereafter. <br /> ❑X (2 ) 87 Drop tube with mechanical overfill at 95 % ❑ Cold start of monitoring panel <br /> ❑ 89-91 Drop tube with mechanical overfill at 95 % ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150- 1 ) ❑ Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> On site for inspection of new overfill flappers on all four tanks (two 87 , 89 , 91 ) . <br /> -Verified measurements with use of tank charts . Overfill shut off is below 95 % . <br /> -Verified flapper functionality . <br /> -Verified removal of ball floats . <br /> This facility is approved to receive fuel . <br /> * Spill container testing was not witnessed . All test results should be submitted to EHD within 30 days . <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD ' S CURRENT HOURLY RATE . <br /> EHD I s ector: Received By: Title : <br /> 1 11,1111,1111: 111111 liiillllp— <br /> EHD 23-04 Rev. /19/12 UST SERVICE REQUEST INSPECTION REPORT <br />