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OP`gU[N' C <br /> ' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> �? 600 East Main Street, Stockton, CA 95202-3029 <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: Inspecti n at <br /> c�nccda 120, ,r <br /> Delta Arco <br /> Facility Address: Service Request#: <br /> 440 W. Dr. Martin Luther King "Jr. Blvd., Stockton SR0062017 <br /> Onsite Service Technician's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <br /> C. Wayne Henderson 17/14/12 VR 6/28/11 <br /> SERVICE SERVICE <br /> Leak detector <br /> 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 /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: <br /> ❑ ❑ electronic Serial#: El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System ❑ Other <br /> UDC 5/6 sensor <br /> ❑ positive shutdown Model: VR 794380-208 Primary piping testing at: <br /> O <br /> x Elx❑fail safe Serial #: 887260 psi <br /> ❑ NA minutes <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#: NotePlease be aware that 21 containment components are required to be tested upon <br /> ElNA 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 /> Q This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> On site to witness verification of UDC 5/6 sensor functionality. Passed. Verified fail safe and sensor <br /> out. <br /> THIS FACILITY IS S E0 TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Re ed By: Title: <br /> EHD 2304 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />