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OAau I N'•.0 <br />SAN JOAQUIN COUNTY <br />Q. ENVIRONMENTAL HEALTH DEPARTMENT <br />�. ;. 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />'4��FO'Kta <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />Waterloo Foodmart <br />Friday, December 31, 2010 <br />Facility Address: <br />Service Request #: <br />4315 E. Waterloo Rd., Stockton <br />SR0060935 <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />Fred Babel <br />Ix. 7/16/11 <br />1 VR 7/30/12 <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />0 <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LIS letter 150-1) <br />❑x 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 ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at.- <br />t:psi <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />VENT ANNUL Sump(s) UST(s) <br />0 <br />Testing for the above components are next due by: <br />N/A <br />Note Please be aware that 20 containment components are required to be tested upon <br />installation, 6 months atter, and every 36 months thereafter. <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 />Inspection of vent sump before backfill. Vent sump annular is filled with Bravo interstitial fluid <br />IMF -1 GAL. Verification of communication by observation tube on opposite side of annular. Pipe <br />monitoring is done by vacuum and was not affected by this repair. <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: Re d By: Title: <br />EHD 23-04UST UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 v <br />