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SAN JOAQUIN COUNTY <br /> z ? ENVIRONMENTAL HEALTH DEPARTMENT <br /> ate.• < <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sogov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Waterloo FoodMart Wednesday, April 6, 2016 <br /> Facility Address: Service Request#: <br /> 4315 E. Waterloo Rd, Stockton, CA 95215 SR0074538 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> Dave Winkler March 1, 2018 Veeder Root Level 4 <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 /> ❑ ❑ electronic Serial#: El 1 hour hydrostatic ❑ Incon TS-STS <br /> 11 line test programmed <br /> El Caldwell System ❑ Other <br /> 91 vent line sensor <br /> El positive shutdown Model: VR-330020-463 Primary piping testing at: <br /> El psi <br /> El fail safe Serial#: 15220003 <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 2°containment components are required to be tested upon <br /> ❑ NA installation,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 /> On site to verify sensor functionality after replacing the 91 vent line vacuum sensor. All test passed. <br /> MSC also done this day. <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Re i By: Title: <br /> EHD 23-04 Rev.04/19/12 UST SERVICE REQUEST INSPECTION REPORT <br />