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IV)! --. <br />00 <br />Escalon Mini Mart <br />Wednesday, January 27, 2016 <br />Facility Address: <br />SAN JOAQUIN COUNTY <br />ur. < <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Onsite Service Technician's Name: <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br />Manufacturer Training: <br />Jose Ochoa <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />Escalon Mini Mart <br />Wednesday, January 27, 2016 <br />Facility Address: <br />Service Request #: <br />1097 E. Yosemite Ave., Escalon <br />SR0074051 <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />Jose Ochoa <br />1/12/18 <br />Incon 2/10/17 <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />Z <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test pro2rammed <br />91 STP sensor <br />© <br />positive shutdown Model: Incon <br />❑ fail safe Serial #: TSP-ULS <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <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 LG letter 150-1) <br />❑X This UST facility is APPROVED to operate <br />SERVICE <br />37 Spill bucket D minimum 5 gallon <br />0 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />97 Spill bucket N minimum 5 gallon <br />Z <br />p 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />_ UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note: Please bP aware that 20 containment components are required to be tested upon <br />installation, 6 months after, 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 />On site to witness testing of sensor functionality for 91 STP sensor, one hour testing of 87 and 91 spill <br />buckets and verify minimum of 5 -gallon capacity and proper drainage. All passed. <br />I THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />By: <br />Title: <br />EHD 23-04 Rev. 04/19/12 UST SERVICE REQUEST INSPECTION REPORT <br />