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Jul .26 2016 01:58PM HP Fax <br />page 4 <br />SAN JOAQUIN COUNTY <br />Ile, ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95206-6232 JUL 2 ZG 5 <br />Telephone: 209 468-3420 Fax. 209 468-3433 ~: www.s o or .lg_ehd ril l <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name. <br />Inspection dais: <br />Super Center Mart <br />Fhday, July 22, 2016 <br />Facility Addreas: <br />Service Requsat It <br />701 E. Charter Way (MLK Blvd.) Stockton, CA 95206 <br />SR0075089 <br />Onske Service Technician's Name: <br />ICC Service TechniclaMnstailer Ep. Data: <br />Manufacturer Training: <br />Joseph Bartholdi <br />18-5-16 <br />Veeder Root 1-28-17 <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />87/91 annular sensor <br />® <br />❑ postale shutdown Model: VR 794390-420 <br />❑ fail safe Serial #-. 1 <br />N NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fall safe Serial #. <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />01 <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />® This UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Inoon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary at: <br />❑ <br />�pipingtesting <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sumps) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Noss: Now oe avers to 2•=-&hnert a mvnenta an Wund to be tested upon <br />IrmtaYtla+, a monde after, and every ae mantte #wwpar. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />On site to witness the functionality test of the 67191 split annular tank. All pass. <br />THIS jj%#Vj0Pi'sj/IS SUVj5j N REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspedo k IV^N� RacaNad By: <br />EHD 23-04 Rey, 04/99/12 UST SERVICE REQUEST INSPECTION REPORT <br />