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�• —.E� •ate SAN JOAQUIN COUNTY <br /> c Z ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sagov.org/ehd <br /> /FOR% <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Delta Arco Tuesday, August 9, 2011 <br /> Facility Address: Service Request#: <br /> 440 W. Dr. Martin Luther King, Jr. Blvd., Stockton SR0063132 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> Joe Bartholdi 17/8/12 VMI x. 8/4/12 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ El mechanical Model:VMI 99 LD-2000 <br /> X ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: 11061257 ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: <br /> El ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> ❑ <br /> El positive shutdown Model: ElPrima Primary testing at: <br /> si <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#: Note Please be aware that 21 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 /> ❑ I Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> 0 This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> Onsite to witness testing of the 87 mechanical line leak detector for 10 psi at 3 gph. Passed. <br /> THIS FACILITY IS S dJE TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Receiv .d Title <br /> L <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />