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N.qu 111Y.. <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> C�fiQ'�iea <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Costco Wholesale #658 1/9/2023 <br /> Facility Address: Service Request#: <br /> 3250 W Grant Line Rd, Tracy CA 95377 SR0086052 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> Justin Zorn 2/12/2023 FF, 6/5/2024 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 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 El1 hour hydrostatic ElIncon TS-STS <br /> ❑ electronic Serial #: <br /> 11 line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> E] ❑ 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 20 containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every 36 months thereafter. <br /> ❑X 87 Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ j 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 overfill prevention on the 87 (T2) tank <br /> -Verified shutoff at <95% with appropriate tank charts <br /> -Verified flapper functionality <br /> -Verified that no ball floats were present. <br /> **This facility is APPROVED to receive fuel in the 87 (T2) tank.** <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: Requestor <br /> Gabriela Garcia-Mejia,EHS Emailed to Bruno Espinoza <br /> EHD 23-04 Rev.04/19/12 UST SERVICE REQUEST INSPECTION REPORT <br />