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R4l!!ly. <br /> >°' SAN JOAQUIN COUNTY <br /> <. �r ENVIRONMENTAL HEALTH DEPARTMENT <br /> I1 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> \\ Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.si.gov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Charter Way Chevron Thursday, October 10, 2013 <br /> Facility Address: Service Request C: <br /> 508 W. Dr. MLK, Jr. Blvd., Stkn. SR0067904 <br /> Onsite Service Technician's Name: ICC Service Technicianlinstaller Exp.Date: Manufacturer Training: <br /> Guadalupe Sanchez 4/20/15 VR x. 11/8/13 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model:VR 848480-001 (w/Swificheck) <br /> (] ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> 9 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 <br /> ❑ ❑ positive shutdown Model: El psi testing at: <br /> ❑fail safe Serial#: 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#: Noe Pleasehea re NatPmntainmentmmmneMsame ulre toy Msteduaan <br /> ❑ NA nslaIatmn,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 /> Witnessed verification testing of the 87 electronic line leak detector, at 3 gph at 10 psi. Passed. <br /> THIS FACILITY IS SUBJECT TO REINSPECTI AT AN I T EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Re tl By: _ Title//: nn <br /> � <br /> EHD 23-04 R / 12 UST SERVICE REQUEST INSPECTION REPORT <br />