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SAN JOAQUIN COUNTY <br /> Q. ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> c'O�iFoa�'�P <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www-s4gov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> )elta Arco Friday, April 15, 2011 <br /> Facility Address: Service Request#: <br /> 440 W. Dr. Martin Luther King "Jr. Blvd.. Stockton SR0062017 <br /> Onsite Service Technician's Name: ICC Siervice Technician/Installer Exp.Date: Manufactu er T fining: <br /> C. Wayne Henderson Z V�• /y <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> El line test ro rammed El Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: <br /> ❑ <br /> El electronic Serial#: ❑ El hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> LDDC 5/6 sensor <br /> ❑ 0 positive shutdown Model: VR 794380-208 Primary piping testing at: <br /> x ❑ psi <br /> El fail safe Serial#: 860429 <br /> minutes <br /> El 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 20 containment components are required to be tested upon <br /> ❑ NA installation,6 months atter,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 LIS letter 150-1) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate ❑Q This UST facility is NOT APPROVED to operate <br /> On site to witness verification of UDC 5/6 sensor functionality. The new sensor did not detect liquid at <br /> the time of inspection. <br /> **The facility cannot operate UDC 5/6 prior to the EHD inspection and approval.** <br /> THIS FACILI IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD IAtor: Received By: Title: <br /> ,- �� �4 <br /> EHD 23 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/1 <br />